Streamlining eClinicalWorks TRICARE Prior Authorization Automation

Klivira provides comprehensive eClinicalWorks TRICARE prior authorization automation, directly integrating with your EMR to manage complex submissions to regional contractors.

For mid-sized ambulatory practices utilizing eClinicalWorks, navigating TRICARE prior authorizations presents unique challenges due to its regional administration and varied submission channels. Manual processes for TRICARE East (Humana Military) and TRICARE West (TriWest) often lead to significant administrative burden and delays, impacting patient care and revenue cycles.

The Challenge of TRICARE Prior Authorizations in eClinicalWorks

TRICARE's administration through regional contractors like Humana Military and TriWest means prior authorization workflows route through distinct provider portals and processes. Integrating these external requirements with eClinicalWorks' diverse data surfaces—from the Patient Hub to Orders—creates a fragmented PA process that demands significant manual effort from prior authorization coordinators.

Klivira's Direct Integration with eClinicalWorks

Klivira leverages eClinicalWorks' robust integration surfaces, including its FHIR R4 APIs and SMART App Launch, to embed prior authorization automation directly within the eCW clinical UI. This approach facilitates seamless data exchange for patient, encounter, coverage, and service request information, significantly reducing context switching and manual data entry for care teams.

Navigating TRICARE's Regional Prior Authorization Channels

Klivira intelligently identifies the beneficiary's TRICARE region (East or West) and routes prior authorization requests through the responsible contractor's portal—either Humana Military or TriWest. This ensures adherence to specific submission channels and leverages TRICARE's published medical policies from tricare.mil, layered with the regional contractor's utilization management operations.

Key Prior Authorization Workflows Automated for eCW + TRICARE

Specialty medication prior authorizations detected at the e-prescribing stage.
Advanced imaging and procedural authorizations, including for referrals.
Durable medical equipment (DME) and home health service requests.
Post-submission status tracking and task management integrated into eCW's Inbox.
Access to TRICARE utilization management policies and guidelines.

Secure Data Exchange and Workflow Integration with eClinicalWorks

Klivira utilizes eClinicalWorks' FHIR R4 read APIs for US Core resources such as Patient, ServiceRequest, and MedicationRequest. For write-back capabilities, Klivira deposits PA documentation as DocumentReference and updates workflow status via Task management, ensuring all prior authorization artifacts are securely accessible within the Patient Hub and Progress Notes.

Compliance and Interoperability Considerations for DHA Beneficiaries

Klivira's approach aligns with evolving interoperability standards, including considerations for CMS-0057-F payer-to-payer data exchange capabilities, often facilitated by platforms like Healow. Clinics should discuss specific data sharing agreements and compliance implications with their internal teams to ensure adherence to HIPAA and ePHI guidelines when managing TRICARE beneficiary data.

Frequently asked questions

How does Klivira handle TRICARE's regional contractors for prior authorizations?

Klivira automatically identifies the TRICARE region (East or West) based on the beneficiary's information and routes the prior authorization request through the appropriate regional contractor's portal, either Humana Military or TriWest.

Can Klivira integrate with my specific eClinicalWorks deployment?

Yes, Klivira integrates with eClinicalWorks using its FHIR R4 APIs and SMART App Launch. This flexible integration supports various eCW deployments, including both cloud-hosted and self-hosted environments.

Where do prior authorization documents and status updates appear within eClinicalWorks?

Prior authorization documents are deposited as DocumentReference resources, visible in the Patient Hub and Progress Notes. Workflow status updates and follow-up tasks are routed directly into eClinicalWorks' Inbox and Task Management system.

Does Klivira support specialty drug prior authorizations for TRICARE beneficiaries?

Absolutely. Klivira integrates with eClinicalWorks' e-prescribing workflows to detect and automate prior authorization requests for specialty medications, streamlining this often complex process for TRICARE members.

What eClinicalWorks data does Klivira access for prior authorizations?

Klivira accesses relevant US Core FHIR resources, including Patient, Encounter, Coverage, ServiceRequest, MedicationRequest, and DocumentReference, to gather the necessary clinical and administrative data for prior authorization submissions.