Automating TRICARE Imaging Prior Auth for Military Health Systems

Understanding TRICARE's Imaging Prior Auth Landscape

TRICARE, the U.S. military health benefit, is administered by regional contractors: Humana Military for TRICARE East and TriWest Healthcare Alliance for TRICARE West. Imaging prior authorizations for TRICARE beneficiaries route through these regional contractors' provider portals and processes, often leveraging specialized radiology benefit managers (RBMs) like eviCore, NIA Magellan, or Carelon Medical Benefits Management (formerly AIM Specialty Health) for clinical review.

Key Challenges in TRICARE Imaging PA Management

• Accurately identifying the correct regional contractor (Humana Military or TriWest) and their specific RBM for each imaging request.
• Navigating varied submission channels and portal requirements across regional contractors and their delegated RBMs.
• Ensuring submitted clinical documentation meets ACR Appropriateness Criteria for advanced imaging, a common framework for medical necessity.
• Managing high volumes of peer-to-peer reviews for clinical denials, impacting clinician time and scheduling.
• Minimizing imaging scheduling delays caused by manual PA processes and backlogs, affecting patient access.

Klivira's Automated Approach to TRICARE Imaging Prior Auth

Klivira's platform integrates directly with your EMR to detect advanced imaging orders (MRI, CT, PET, nuclear) at the point of care. Our system intelligently identifies the responsible TRICARE regional contractor and their specific RBM, automating the submission process. This ensures that requests are routed correctly and reviewed against TRICARE's medical policies, which are often layered with the RBM's utilization management criteria.

Automated Workflow for TRICARE Imaging PA

• **EMR Order Detection:** Klivira receives a CDS Hook event when an advanced imaging order is placed, initiating the PA workflow.
• **Payer & RBM Identification:** The system automatically determines the TRICARE region (East/West) and routes to the correct regional contractor's portal or delegated RBM (e.g., eviCore, NIA Magellan, Carelon).
• **ACR Appropriateness Check:** Klivira evaluates the order against ACR Appropriateness Criteria before submission, ensuring clinical documentation aligns with medical necessity guidelines.
• **Pre-submission Recommendations:** If an order doesn't meet appropriateness thresholds, Klivira can surface alternative imaging recommendations to the clinician at order entry, preventing denials.
• **Automated Submission:** All required clinical data, including ICD-10 diagnoses, prior imaging, and conservative care trials, are populated from FHIR data and submitted via the appropriate channel (e.g., X12 278, RBM portal).
• **Response Handling:** Approvals are automatically processed for scheduling, while modification recommendations and denials are routed for efficient clinician review and peer-to-peer scheduling.

Enhancing Compliance and Operational Efficiency

Implementing Klivira for TRICARE imaging prior authorizations significantly reduces manual errors and improves adherence to TRICARE's published medical policies and regional contractor operational implementations. By automating the end-to-end process, clinics and health systems can accelerate patient access to critical imaging services, reduce administrative burden, and ensure better alignment with evolving regulatory considerations like those outlined in CMS-0057-F.

Integration with TRICARE Regional Contractors and RBMs

Klivira's robust connectivity ensures seamless integration with the provider portals and EDI endpoints of both Humana Military (TRICARE East) and TriWest Healthcare Alliance (TRICARE West). This includes direct submission capabilities to their commonly utilized radiology benefit management partners, such as eviCore, NIA Magellan, and Carelon Medical Benefits Management, ensuring that TRICARE imaging prior authorizations are processed efficiently and accurately, regardless of the specific routing requirements.