Streamlining NextGen Healthcare TRICARE Prior Authorization Automation

Klivira delivers NextGen Healthcare TRICARE prior authorization automation, addressing the complexities of military health benefits and regional contractor workflows within your ambulatory EMR.

For revenue cycle directors and prior authorization coordinators at specialty ambulatory groups utilizing NextGen Healthcare, navigating TRICARE's unique prior authorization requirements presents a distinct challenge. The need to route requests through regional contractors like Humana Military and TriWest, combined with the administrative burden of manual processes, can significantly impact claim denials and staff productivity.

The TRICARE PA Challenge within NextGen Workflows

TRICARE's structure, administered regionally by contractors (Humana Military for TRICARE East and TriWest Healthcare Alliance for TRICARE West), means prior authorization submissions are not centralized. This necessitates understanding specific contractor portals and processes, adding layers of complexity to the already demanding PA workflow originating from NextGen Enterprise or NextGen Office. Manual submission via multiple portals, often requiring data re-entry from the NextGen patient chart, introduces inefficiency and potential for error.

Seamless Integration with NextGen Healthcare

Klivira integrates directly with NextGen Healthcare using modern interoperability standards. Our platform leverages NextGen's FHIR R4 endpoints for critical data exchange, including Patient, Encounter, Coverage, and ServiceRequest resources. We also utilize SMART App Launch capabilities to embed PA workflows directly within the NextGen clinical UI, providing patient and encounter context without requiring staff to leave their primary EMR environment. This ensures that clinical documentation and orders initiated in NextGen, such as for specialty medications or advanced imaging, are seamlessly routed for PA processing.

Automating TRICARE Regional Contractor Submissions

Klivira's platform intelligently identifies the TRICARE beneficiary's region (East or West) and automatically routes prior authorization requests through the responsible contractor's digital channels. This includes connectivity to Humana Military's and TriWest's provider portals, automating the submission of X12 278 transactions where supported, and managing necessary documentation uploads. Our system layers the TRICARE-specific medical policy framework, accessible via tricare.mil, with the regional contractor's operational utilization management processes to ensure accurate and compliant submissions.

Optimizing PA Workflows for Ambulatory Specialties

Given NextGen's focus on mid-sized specialty ambulatory groups, Klivira's automation is designed to optimize PA workflows for high-volume services common in these settings. This includes streamlining prior authorizations for specialty medications, complex diagnostic imaging, and surgical procedures. By automating the extraction of clinical data from NextGen's Patient Chart and Documents/Clinical Documents sections, and facilitating write-back of PA status to Orders activity and Tasks/Worklists, Klivira minimizes manual intervention and accelerates decision times.

Key Benefits for NextGen + TRICARE Prior Authorization

Direct FHIR R4 integration with NextGen Healthcare for clinical and administrative data.
Automated routing of PA requests to TRICARE East (Humana Military) and TRICARE West (TriWest).
Reduced manual data entry and re-keying between NextGen and payer portals.
Improved visibility into PA status within NextGen's Orders activity and Tasks/Worklists.
Enhanced compliance with TRICARE's regional and medical policy requirements.
Accelerated turnaround times for critical specialty services and medications.

Frequently asked questions

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

Klivira's platform automatically identifies the TRICARE beneficiary's region (East or West) and routes prior authorization requests to the appropriate contractor, either Humana Military or TriWest. We connect directly to their provider portals and systems to ensure efficient and accurate submission.

What specific NextGen Healthcare integration methods does Klivira utilize?

Klivira integrates with NextGen Healthcare primarily through its FHIR R4 endpoints for data exchange, covering resources like Patient, Coverage, and ServiceRequest. We also support SMART App Launch to embed our application directly within the NextGen clinical user interface, providing seamless context for PA workflows.

Can Klivira help with prior authorization differences between TRICARE Prime and TRICARE Select?

Yes, network status (TRICARE Prime vs. Select) can affect prior authorization scope. Klivira's system is designed to factor in these nuances, helping to ensure that submissions align with the specific requirements based on the beneficiary's TRICARE plan and network status.

Where do prior authorization artifacts appear in NextGen after Klivira processes them?

After Klivira processes a prior authorization, relevant artifacts and status updates are written back into NextGen. This typically includes updates in the Orders activity, the Documents/Clinical Documents section for supporting materials, and the Tasks/Worklists system for follow-up actions.

Is Klivira compatible with both cloud-hosted and self-hosted NextGen deployments?

Klivira's integration approach is designed to accommodate the variability of NextGen deployments, including both cloud-hosted and self-hosted models. Our team works with your IT integration leads to ensure compatibility regardless of your specific NextGen infrastructure.