Automating Epic Prior Authorization for Genetic Testing

Klivira streamlines **Epic prior authorization for genetic testing**, enabling health systems to accelerate approvals for complex genomic orders directly within their Epic workflow.

For large health systems and academic medical centers leveraging Epic, managing prior authorizations for genetic testing presents unique challenges. High-volume categories like hereditary cancer panels, prenatal, and pharmacogenomics frequently involve external RBMs and complex documentation requirements, leading to significant administrative burden and potential delays in patient care. Klivira integrates directly with Epic to automate these workflows.

The Challenge of Genetic Testing PAs within Epic

Genetic testing orders, often placed within Epic Hyperspace or Hyperdrive, frequently trigger prior authorization requirements from payers or specialized RBMs like eviCore and Avalon Healthcare Services. The manual process of context-switching from Epic to external payer portals or faxing documentation disrupts clinical workflows and can lead to delayed patient access to critical genomic insights.

Seamless Klivira Integration with Epic for Genetic Testing Orders

Klivira leverages Epic's robust integration surfaces, including SMART on FHIR and CDS Hooks, to embed prior authorization automation directly into the clinician's workflow. When a genetic testing order, such as a hereditary cancer panel or pharmacogenomics test, is placed in Epic's Orders activity, Klivira can surface real-time coverage requirements and initiate the PA process without leaving Hyperspace.

Key Integration Points for Genetic Testing PA in Epic

**SMART on FHIR Launch**: Klivira launches as an EHR-embedded app from within Hyperspace or Hyperdrive, carrying patient and encounter context for genetic testing orders.
**CDS Hooks**: Utilizes `order-select` and `order-sign` hooks to detect genetic testing orders and prompt for PA requirements at the point of care, aligning with Da Vinci CRD principles.
**FHIR R4 Read/Write**: Accesses patient data (e.g., Condition, Observation, ServiceRequest) from Epic for PA submission and writes back DocumentReference for authorization packets and Communication for status updates.
**Automated Documentation Retrieval**: Aggregates necessary clinical notes, lab results, and imaging from Epic's Chart Review and Media sections to build comprehensive PA packets.
**Inbasket Task Routing**: Delivers PA status updates and requests for additional information directly to the responsible care team within Epic's Inbasket module.

Addressing RBM Complexity for Genetic Testing

Genetic testing prior authorizations are frequently routed through specialized RBMs such as eviCore and Avalon Healthcare Services. Klivira's platform is designed to navigate the specific documentation requirements and submission channels of these RBMs, reducing the manual burden on prior authorization coordinators and ensuring accurate, timely submissions for high-volume categories like hereditary cancer panels.

Driving Efficiency for Genetic Testing Workflows in Epic

By automating the prior authorization process for genetic testing within Epic, Klivira helps eliminate common pain points like manual faxing, fragmented payer portal access, and extensive context switching. This allows revenue cycle teams and prior authorization coordinators to focus on complex cases, reduce denial rates, and improve turnaround times for critical genomic tests.

Frequently asked questions

How does Klivira integrate with Epic for genetic testing orders?

Klivira integrates with Epic using SMART on FHIR for app launch within Hyperspace/Hyperdrive and FHIR R4 APIs for data exchange. We leverage CDS Hooks to detect genetic testing orders at the point of entry, allowing for real-time PA initiation and documentation gathering directly from Epic's Chart Review and Orders activity.

Can Klivira handle prior authorizations for specific genetic testing panels like hereditary cancer?

Yes, Klivira is designed to manage prior authorizations for high-volume genetic testing categories including hereditary cancer panels, prenatal genetic testing, and pharmacogenomics. Our system adapts to the specific clinical documentation requirements for these tests, streamlining the submission process.

How does Klivira address RBMs like eviCore or Avalon for genetic testing PAs?

Klivira maintains connectivity with common RBMs that manage genetic testing prior authorizations, such as eviCore and Avalon Healthcare Services. Our platform automates the submission process, ensuring that the specific data elements and documentation required by these RBMs are accurately transmitted.

What Epic modules does Klivira interact with for genetic testing prior authorization?

Klivira interacts with Epic's Orders activity for PA detection, Chart Review and Media for documentation retrieval, and Inbasket for status updates and task routing. The integration is designed to be seamless within the Hyperspace/Hyperdrive user experience, minimizing context switching for users.

Does Klivira write back PA status or authorization numbers to Epic?

Yes, Klivira can write back key prior authorization artifacts to Epic. This includes depositing the full authorization packet as a DocumentReference and sending status updates or authorization numbers via Communication or Task resources, making the information visible within the patient's chart and Inbasket.