Centricity TRICARE Prior Authorization Automation

Achieving efficient Centricity TRICARE prior authorization automation requires navigating the unique operational nuances of a government payer administered by regional contractors.

For revenue cycle directors and prior authorization coordinators, managing TRICARE prior authorizations from a Centricity environment presents distinct challenges. The need to integrate with regional contractors while leveraging a legacy EMR system can introduce complexity and manual effort into critical workflows.

The Centricity-TRICARE Prior Authorization Challenge

Healthcare organizations utilizing Centricity often face a dual challenge: optimizing workflows within a system that has transitioned under athenahealth, while simultaneously adhering to the specific prior authorization requirements of TRICARE. This includes identifying the correct regional contractor—Humana Military for TRICARE East or TriWest Healthcare Alliance for TRICARE West—and routing submissions appropriately, which can strain existing PA processes.

Navigating TRICARE's Regionalized Prior Authorization Pathways

TRICARE's prior authorization process is decentralized, routing through its regional contractors. Submissions for TRICARE East beneficiaries are managed via Humana Military's provider portal and associated PA processes. Similarly, for TRICARE West, workflows route through TriWest Healthcare Alliance's designated provider channels. Klivira's platform is engineered to identify the correct regional contractor and facilitate submissions through their specific portals, layering TRICARE's published medical policies from tricare.mil with the contractor's utilization management operations.

Klivira's Integration with Centricity via Athena APIs

Klivira integrates with Centricity environments, leveraging Athena APIs to extract necessary patient demographics, clinical documentation, and order details. This approach ensures that prior authorization requests are initiated directly from the EMR, reducing data entry errors and streamlining the handoff to Klivira's automation engine. Our solution is designed to support organizations managing legacy Centricity installs being migrated, providing a consistent PA workflow.

Optimizing TRICARE Prior Authorization Workflows

Automated identification of TRICARE beneficiary region (East or West) to route to the correct contractor.
Direct submission to Humana Military or TriWest provider portals, minimizing manual intervention.
Application of TRICARE medical policies in conjunction with regional contractor-specific UM criteria.
Support for complex service lines including specialty medications, advanced imaging, and surgical procedures.
Real-time status updates and documentation management within the Centricity workflow.
Adaptation for network status considerations (TRICARE Prime vs. Select) that impact PA scope.

Addressing Key TRICARE Service Lines and Medications

TRICARE's utilization management often focuses on high-cost or high-utilization services. Klivira's platform supports the specific prior authorization requirements for specialty drugs, including biologics and oncology agents, which frequently require detailed clinical documentation. We also facilitate the routing of imaging requests and surgical procedure PAs, ensuring that all necessary information is submitted to the appropriate regional contractor, whether Humana Military or TriWest.

Frequently asked questions

How does Klivira handle the regional differences for TRICARE PAs?

Klivira's system automatically identifies whether a TRICARE beneficiary falls under the East or West region. Based on this, it routes the prior authorization request to the respective regional contractor—Humana Military for TRICARE East or TriWest Healthcare Alliance for TRICARE West—using their specific provider portals and submission channels.

Can Klivira integrate with my specific Centricity version?

Klivira integrates with Centricity environments primarily through Athena APIs, accommodating organizations managing legacy installs. Our solution is designed to extract necessary patient and clinical data from your EMR to power automated prior authorization submissions.

Does Klivira apply TRICARE's medical policies?

Yes, Klivira incorporates TRICARE's published medical policies, found on tricare.mil, and layers them with the operational utilization management criteria of the regional contractors (Humana Military, TriWest). This ensures that submissions align with both TRICARE-wide guidelines and contractor-specific requirements.

What types of services does Klivira automate for TRICARE?

Klivira automates prior authorizations for a broad range of services relevant to TRICARE, including specialty medications, advanced diagnostic imaging, surgical procedures, and other high-cost or high-utilization treatments. Our platform is designed to handle the varied documentation requirements for these service lines.

How does Klivira improve PA turnaround times for Centricity and TRICARE?

By automating data extraction from Centricity via Athena APIs and directly submitting to TRICARE's regional contractor portals, Klivira significantly reduces manual steps and potential errors. This streamlined process aims to accelerate submission times and facilitate quicker responses from Humana Military or TriWest.