Streamlining TruBridge (CPSI) Aetna Prior Authorization Automation

Klivira provides comprehensive TruBridge (CPSI) Aetna prior authorization automation, integrating directly with your EMR to streamline complex medical and pharmacy benefit requests for rural and community hospitals.

For revenue cycle directors and prior authorization coordinators at TruBridge (CPSI) powered hospitals, managing Aetna's diverse prior authorization requirements can be a significant operational challenge. Klivira addresses this by automating the submission and tracking of medical and pharmacy prior authorizations, reducing manual effort and accelerating decision times.

Navigating Aetna Prior Authorization Channels from TruBridge

Aetna, a national insurer with a strong presence in commercial and Medicare Advantage, utilizes distinct channels for prior authorization submissions. Klivira's platform is engineered to connect with these channels, ensuring TruBridge (CPSI) users can efficiently manage Aetna PA requests without navigating disparate portals. This includes medical PA via the Availity provider portal and X12 278 transactions, and pharmacy PA through ePA partners like CoverMyMeds and Surescripts.

Seamless Integration with TruBridge (CPSI) EMR

Klivira integrates directly with TruBridge (CPSI) and its aliases, including Evident and Thrive EHR, through the TruBridge API. This deep integration allows for the automated extraction of necessary clinical documentation and patient demographic data directly from the EMR, populating Aetna's prior authorization forms and reducing the need for manual data entry. For rural and community hospitals, this means a more efficient and less error-prone PA workflow, directly embedded within their existing EMR environment.

Aetna Prior Authorization Submission Pathways

**Medical Benefit PA:** Klivira automates submissions to Aetna via the Availity provider portal for commercial and Medicare Advantage lines, and supports X12 278 transactions for applicable procedure categories.
**Pharmacy Benefit PA:** For outpatient retail and mail-order pharmacy benefits, Klivira routes requests through Aetna's ePA partners, CoverMyMeds or Surescripts, administered by CVS Caremark.
**Specialty Drug PA:** Klivira supports the specific workflows for specialty injectable and infused medications managed under the medical benefit, aligning with Aetna's specialty-pharmacy-management processes.
**Inpatient Admission Notifications:** Automated submission of concurrent review intake, adhering to Aetna's specific notification windows and state regulations.
**Policy Adherence:** Klivira leverages Aetna's Clinical Policy Bulletins (CPBs) to ensure submissions align with medical necessity criteria for procedures like advanced imaging or oncology biologics, referencing CPB numbers for accuracy.

Navigating Aetna's Policy and Turnaround Time Requirements

Aetna's medical necessity criteria are published as Clinical Policy Bulletins (CPBs), which are versioned and publicly available. Klivira's platform helps ensure submissions meet these criteria, reducing denials. Turnaround times are governed by state insurance regulations and NCQA Utilization Management accreditation standards. For Aetna's Medicare Advantage, Medicaid, and QHP lines, CMS-0057-F mandates 72-hour decisions for standard PA requests and 24-hour for expedited requests, which Klivira helps health systems monitor and meet. The commercial line of business is not directly impacted by CMS-0057-F.

Optimizing Denial Management and Appeals for TruBridge Users

When denials occur, Aetna returns reasons via X12 835/277 transactions or portal updates, utilizing CARC and RARC vocabularies. Klivira streamlines the review of common denial categories such as medical necessity, step therapy, or site-of-service mismatches. Our platform facilitates the appeal pathway, from reconsideration to formal appeals, by organizing necessary documentation and tracking timely-filing windows, improving the likelihood of successful resolution for TruBridge (CPSI) facilities.

Frequently asked questions

How does Klivira integrate with TruBridge (CPSI) for Aetna prior authorizations?

Klivira integrates with TruBridge (CPSI) and its associated EMRs like Evident and Thrive EHR via the TruBridge API. This allows for automated data exchange, pulling patient demographics and clinical documentation directly from the EMR to populate Aetna's prior authorization requests, minimizing manual data entry and speeding up the submission process.

Which Aetna prior authorization channels does Klivira support for TruBridge users?

Klivira supports Aetna's primary prior authorization channels. For medical benefits, this includes submission through the Availity provider portal and via X12 278 transactions. For pharmacy benefits, Klivira integrates with Aetna's ePA partners, CoverMyMeds and Surescripts, administered by CVS Caremark.

Does Klivira help TruBridge users comply with Aetna's Clinical Policy Bulletins (CPBs)?

Yes, Klivira helps ensure that prior authorization submissions from TruBridge (CPSI) facilities align with Aetna's Clinical Policy Bulletins (CPBs). Our automation platform assists in identifying and gathering the documentation required by specific CPBs, such as those for advanced imaging or specialty medications, to support medical necessity and reduce the risk of denials.

How does Klivira address Aetna's varying prior authorization turnaround times for TruBridge (CPSI) clients?

Klivira's platform tracks Aetna's prior authorization requests against state-mandated minimums and payer-published service-level targets. For Aetna's Medicare Advantage and certain other lines of business, Klivira helps monitor compliance with CMS-0057-F requirements for 72-hour standard and 24-hour expedited decisions, providing visibility and alerts to meet these critical deadlines.

Can Klivira assist with Aetna prior authorization denials and appeals for TruBridge EMR users?

Absolutely. Klivira streamlines the denial management process by helping to interpret Aetna's denial reasons (CARC/RARC codes) received via electronic transactions or portal updates. The platform assists TruBridge (CPSI) users in preparing and submitting appeals by organizing necessary clinical documentation and tracking appeal deadlines, supporting reconsideration and formal appeal processes.