AdvancedMD Anthem (Elevance Health) Prior Authorization Automation

Klivira delivers robust AdvancedMD Anthem (Elevance Health) prior authorization automation, specifically designed for ambulatory specialty practices navigating the complexities of multi-channel payer requirements.

Revenue cycle directors and prior authorization coordinators at AdvancedMD-powered clinics face significant operational overhead when managing prior authorizations for Anthem-licensed plans. The diverse submission channels, varying clinical criteria, and manual data entry processes often lead to delays, denials, and reduced staff productivity. Klivira addresses these challenges by integrating directly with your EMR to streamline the entire PA lifecycle.

Navigating Anthem's Diverse Prior Authorization Submission Channels from AdvancedMD

Anthem-licensed plans, part of Elevance Health, utilize multiple distinct pathways for prior authorization submissions. For ambulatory specialty practices using AdvancedMD, understanding and correctly routing these requests is critical. Klivira automates this complex routing, ensuring submissions reach the correct channel, whether it's for medical, pharmacy, or specialty benefits, directly from your AdvancedMD environment.

Key Anthem (Elevance Health) Prior Authorization Channels

**Medical Benefit PA (Commercial & Medicare Advantage):** Primarily routed through Availity Essentials, Anthem's multi-payer provider workspace, supporting X12 278 transactions via clearinghouses.
**Pharmacy Benefit PA:** Managed by CarelonRx (formerly IngenioRx), supporting ePA submissions through CoverMyMeds and Surescripts for prescriber-initiated workflows.
**Specialty Benefits Management:** Advanced imaging, cardiology, MSK, sleep, and radiation oncology PAs are routed through Carelon Medical Benefits Management (formerly AIM Specialty Health) via their dedicated provider portal.
**Behavioral Health PA:** Often managed by Carelon Behavioral Health (formerly Beacon Health Options), requiring verification for carve-out versus in-network handling.
**Specialty Drug PA (Medical Benefit):** Subject to Anthem's site-of-care and clinical-indication policies, with some categories also routing through Carelon.

Klivira's Seamless Integration with AdvancedMD for Prior Authorization Automation

Klivira connects directly with AdvancedMD leveraging the AdvancedMD API. This robust integration facilitates automated data extraction from patient charts, pre-populates prior authorization forms, and enables direct submission to Anthem's various channels. By removing manual touchpoints, Klivira reduces administrative burden, minimizes errors, and accelerates the prior authorization process for your ambulatory specialty practice.

Automated Policy Adherence and Clinical Criteria for Anthem Services

Effectively managing Anthem prior authorizations requires precise adherence to their specific medical policies and clinical utilization management guidelines. Klivira helps your team navigate this by providing access to criteria published via Availity for standard medical PAs, and directing to Carelon Medical Benefits Management's portal for advanced imaging or MSK procedures. This proactive approach helps ensure submissions align with Anthem-developed, Carelon-developed, MCG-based, or NCCN-compendium-based criteria.

Optimizing Turnaround Times and Managing CMS-0057-F Compliance

Klivira helps ambulatory practices using AdvancedMD to meet and track Anthem's varied prior authorization turnaround times. While commercial PA timeframes are governed by state regulations, Anthem's Medicare Advantage and Medicaid managed-care plans are impacted by CMS-0057-F, mandating 72-hour standard and 24-hour expedited decision timeframes. Our platform provides the visibility needed to manage these deadlines and improve patient access to care.

Proactive Management of Anthem Prior Authorization Denials and Appeals

Anthem denials, communicated via X12 277/835 transactions and Availity status updates, often stem from medical necessity, step therapy, or site-of-service mismatches. Klivira provides tools to identify common denial patterns and streamline the appeal process. This includes navigating the standard Anthem operating-company appeals process for medical PAs and the separate Carelon-managed appeal pathway for procedures under Carelon Medical Benefits Management, helping your practice recover lost revenue.

Frequently asked questions

How does Klivira integrate with AdvancedMD for Anthem prior authorizations?

Klivira integrates with AdvancedMD via the AdvancedMD API. This connection enables automated extraction of patient demographic and clinical data, which is then used to pre-populate prior authorization forms and initiate submissions to the appropriate Anthem (Elevance Health) channels, reducing manual data entry and errors.

Which Anthem (Elevance Health) prior authorization channels does Klivira support?

Klivira supports all major Anthem (Elevance Health) prior authorization channels. This includes Availity Essentials for medical benefit PAs, ePA partners like CoverMyMeds and Surescripts for pharmacy PAs via CarelonRx, and the dedicated provider portal for Carelon Medical Benefits Management for specialty services like advanced imaging.

Can Klivira help with prior authorizations for advanced imaging or specialty drugs covered by Anthem?

Yes, Klivira specifically addresses the complexities of advanced imaging and specialty drug prior authorizations for Anthem. We streamline submissions to Carelon Medical Benefits Management for imaging, cardiology, and MSK services, and facilitate medical-benefit specialty drug PAs, ensuring compliance with Anthem's site-of-care and clinical-indication policies.

How does Klivira assist with Anthem's varied medical policies and clinical guidelines?

Klivira helps your team navigate Anthem's extensive medical policy and clinical UM guideline libraries. We provide tools to access the correct criteria, whether it's Anthem-developed policies via Availity or Carelon Medical Benefits Management guidelines for specific procedures, ensuring your submissions are evidence-grounded and compliant.

Does Klivira help manage denials and appeals for Anthem prior authorizations?

Yes, Klivira offers features to manage Anthem prior authorization denials and appeals. Our platform provides insights into common denial reasons and streamlines the appeal submission process, including navigating the distinct appeal pathways for Carelon Medical Benefits Management denials. This helps your practice efficiently address and overturn denials.