Streamlining Epic Prior Authorization for DME Workflows

The Challenge of DME Prior Authorization in Epic

For large health systems and academic medical centers utilizing Epic, the prior authorization process for durable medical equipment—such as power mobility, CPAP/BiPAP devices, prosthetics, orthotics, and ostomy supplies—is often characterized by manual fax workflows and fragmented access to payer portals. Clinicians and prior authorization coordinators frequently experience context switching out of Hyperspace or Hyperdrive, diverting focus from direct patient care and contributing to delays in obtaining necessary approvals. This creates significant administrative overhead and can impact patient access to essential equipment.

Klivira's Embedded Integration for Epic DME Workflows

Klivira integrates with Epic via SMART App Launch, enabling a seamless EHR-launch directly from within Hyperspace or Hyperdrive. This allows prior authorization workflows to be initiated with patient and encounter context, eliminating the need for manual data entry and reducing errors. Our solution surfaces coverage requirements and automates documentation assembly at critical points, such as the Orders activity, where a clinician places the order triggering a PA requirement.

Key Integration Points for DME PA Automation

• **SMART on FHIR Launch:** Klivira launches directly from Epic's Hyperspace or Hyperdrive, leveraging SMART scopes to access patient and encounter context.
• **CDS Hooks for Order Entry:** Integration with CDS Hooks (`order-select`, `order-sign`) in the Orders activity to detect PA requirements for DME at the point of order.
• **FHIR R4 Data Exchange:** Securely reads clinical documentation from Chart Review (Notes, Imaging, Labs, Documents) and other relevant FHIR resources (e.g., Condition, Observation) to build comprehensive PA packets.
• **DocumentReference Write-back:** Deposits completed prior authorization packets and approval documents back into the Epic chart as FHIR DocumentReference resources.
• **Communication and Task Updates:** Writes status updates and tasks to Epic's Inbasket module, ensuring clinicians and coordinators are informed of PA progress without leaving their native workflow.
• **Longitudinal Record Aggregation:** Utilizes `Patient/$everything` for comprehensive patient history extraction, crucial for supporting medical necessity for complex DME.

Automating High-Volume DME Categories

The high volume of prior authorization requests for categories like power mobility, CPAP/BiPAP, and prosthetics/orthotics demands an automated approach. Klivira's integration with Epic specifically targets these areas by automating the identification of required documentation, drafting the PA request, and facilitating submission. By leveraging Epic's FHIR R4 read capabilities for resources such as ServiceRequest and DocumentReference, Klivira ensures that all necessary clinical evidence is aggregated efficiently, reducing the potential for denials and accelerating patient access to critical equipment.

Operational Benefits for Revenue Cycle and Clinical Teams

Implementing Klivira for Epic prior authorization for DME translates into tangible operational benefits. Revenue cycle directors can expect a reduction in denial rates and faster turnaround times for DME approvals, improving financial performance. Prior authorization coordinators gain efficiency by eliminating manual data entry and context switching, allowing them to manage more cases with greater accuracy. Clinicians benefit from a streamlined workflow that keeps them within Hyperspace/Hyperdrive, reducing administrative burden and enabling them to focus on patient care.