Streamlining Pulmonology SMART on FHIR Prior Auth Workflows

Klivira's platform optimizes pulmonology SMART on FHIR prior auth by embedding automation directly within the EMR, addressing the unique complexities of respiratory care. This integration reduces administrative burden and accelerates access to critical treatments.

Revenue cycle directors and prior authorization coordinators in pulmonology face distinct challenges, from managing high-cost biologics to ensuring timely approval for durable medical equipment like home oxygen and BiPAP. The traditional prior authorization process, often requiring context-switching and manual data entry, disrupts clinical workflows and contributes to delays in patient care. Klivira addresses these inefficiencies by integrating directly into the EMR via SMART on FHIR.

The Challenge of Pulmonology Prior Authorizations

Pulmonology prior authorizations frequently involve complex clinical criteria for high-cost medications such as asthma biologics (Dupixent, Nucala, Fasenra, Tezspire) and IPF antifibrotics (Esbriet, Ofev), alongside essential durable medical equipment like home oxygen and BiPAP. These requirements, often guided by ATS, GOLD, and GINA guidelines, necessitate precise documentation of eosinophil counts, step-therapy adherence, and exacerbation history. Manual workflows for these complex cases frequently lead to administrative errors and delays.

High-Volume Prior Authorization Triggers in Pulmonology

Asthma biologics (e.g., omalizumab, mepolizumab, dupilumab, tezepelumab) with specific eosinophil count and step-therapy requirements.
Home oxygen and BiPAP/CPAP therapies, often overlapping with sleep medicine.
IPF antifibrotics (pirfenidone, nintedanib) requiring documentation of disease progression and prior therapies.
COPD specialty drugs (e.g., ensifentrine) and triple-therapy inhalers subject to step-therapy protocols.
Pulmonary function testing and advanced imaging, depending on payer policies.
Lung transplant evaluations and associated immunosuppression regimens.

Transforming Pulmonology Workflows with SMART on FHIR

SMART on FHIR provides a standardized framework for launching prior authorization applications directly within the EMR, such as Epic, Cerner, athenahealth, and MEDITECH. This integration eliminates context-switching, allowing pulmonologists and PA coordinators to initiate and manage requests without leaving the clinical interface. By leveraging FHIR R4, relevant patient data—from diagnoses to lab results like eosinophil counts—is automatically pulled, reducing manual transcription errors and ensuring comprehensive documentation.

Klivira's SMART on FHIR Advantages for Pulmonology

**In-EMR Launch:** Clinicians initiate PA workflows directly from Epic Hyperspace, Cerner PowerChart, or other supported EMRs, maintaining focus on patient care.
**Automated Data Capture:** FHIR R4 reads US Core resources, including critical eosinophil counts and medication history, eliminating manual data entry for asthma biologics.
**Da Vinci PAS Integration:** Supports Da Vinci CRD for coverage discovery and Da Vinci DTR for documentation templates, streamlining complex pulmonology criteria.
**Structured Write-back:** PA decisions and statuses are written back to the EMR as DocumentReference or Task resources, ensuring queryable and consistent record-keeping.
**Reduced Denial Reasons:** Proactive identification of step-therapy requirements and eosinophil thresholds helps mitigate common denial reasons for biologics.

Klivira's Comprehensive Approach to Pulmonology PA

Klivira's platform is engineered to navigate the specific complexities of pulmonology prior authorizations. Our system incorporates GINA/GOLD/ATS-aware step-therapy logic and automates the documentation of essential clinical criteria, such as eosinophil counts, directly from the EMR. This targeted approach ensures that prior authorization requests for high-cost biologics, home oxygen, and other critical pulmonary treatments are complete, accurate, and aligned with payer requirements, minimizing delays and improving patient access to care.

Frequently asked questions

How does SMART on FHIR specifically benefit pulmonology prior authorizations for asthma biologics?

For asthma biologics like Dupixent or Nucala, SMART on FHIR allows Klivira to automatically pull crucial patient data, such as eosinophil counts and prior controller therapy history, directly from the EMR. This eliminates manual data entry, ensures accuracy, and helps meet payer-specific step-therapy and clinical criteria, reducing common denial reasons.

Which EMRs support SMART on FHIR for prior authorization workflows in pulmonology?

Klivira's SMART on FHIR integration is compatible with major EMR platforms including Epic, Cerner, athenahealth, and MEDITECH. These systems support the SMART App Launch standard, enabling our application to seamlessly embed within the clinical UI and access patient data via FHIR R4.

What are the most common pulmonology treatments requiring prior authorization that Klivira handles?

Klivira automates prior authorizations for high-volume pulmonology treatments including asthma biologics (e.g., Tezspire, Fasenra), home oxygen, BiPAP/CPAP, and IPF antifibrotics (e.g., Ofev). Our system is designed to manage the specific documentation and step-therapy requirements associated with these therapies.

Does Klivira's SMART on FHIR integration address payer-specific step-therapy requirements for pulmonology drugs?

Yes, Klivira's platform incorporates intelligent logic to address payer-specific step-therapy requirements, particularly for asthma biologics and COPD specialty drugs. By integrating with Da Vinci CRD and DTR, our system helps ensure that documentation aligns with payer policies, such as requiring a high-dose ICS-LABA trial before biologic approval.

Is Da Vinci PAS the same as SMART on FHIR?

No, they are distinct but complementary standards. SMART on FHIR defines how applications securely launch and exchange data with an EMR. Da Vinci PAS (Prior Authorization Support) is a set of FHIR-based implementation guides that build upon SMART on FHIR, defining the specific data exchange for prior authorization workflows, including coverage requirements discovery (CRD) and documentation templates (DTR).