TruBridge (CPSI) Anthem (Elevance Health) Prior Authorization Automation

Streamlining TruBridge (CPSI) Anthem (Elevance Health) Prior Authorization Workflows

For rural and community hospitals leveraging TruBridge (CPSI), managing prior authorizations for Anthem (Elevance Health) plans often involves a fragmented process across multiple payer interfaces. Klivira centralizes these diverse requirements, providing a unified platform to submit, track, and manage all Anthem prior authorizations directly from your EMR. This integration is designed to enhance efficiency and reduce the administrative overhead inherent in manual PA processes.

Klivira's Integration with TruBridge (CPSI)

• Leverages the TruBridge API for secure, bi-directional data exchange of clinical and administrative information.
• Automates the extraction of necessary patient demographics, diagnoses, and procedure codes from the TruBridge EMR.
• Facilitates real-time status updates and document attachments directly within your TruBridge workflows.
• Designed for the specific operational context of rural and community hospitals using TruBridge (CPSI), Evident, or Thrive EHR.

Navigating Anthem's Diverse Prior Authorization Channels

Anthem-licensed plans utilize a multi-pronged approach for prior authorization submissions. Medical benefit PAs, including inpatient admission notifications, primarily route through Availity Essentials, which serves as Anthem's multi-payer provider portal. Pharmacy benefit PAs are managed by CarelonRx, often leveraging ePA partners like CoverMyMeds and Surescripts. Specialized services such as advanced imaging and cardiology are directed through Carelon Medical Benefits Management, requiring distinct submission pathways and policy adherence. Klivira is engineered to connect to each of these channels seamlessly.

Automating Complex Anthem Medical Benefit Prior Authorizations

Klivira automates the submission of medical benefit prior authorizations to Anthem, whether via the Availity portal or through X12 278 transactions with your clearinghouse. This includes high-volume surgical procedures, specialty injectables, and infusions subject to Anthem's site-of-care and clinical-indication policies. Our platform ensures that necessary clinical documentation is accurately transmitted, reducing the potential for denials due to insufficient information.

Optimizing Specialty Benefit Management with Carelon MBM

For advanced imaging, cardiology, musculoskeletal, sleep, and radiation oncology services, Anthem utilizes Carelon Medical Benefits Management (formerly AIM Specialty Health). These domains require submission through Carelon MBM's dedicated provider portal. Klivira streamlines this process by automating data entry and tracking for these specific requests, ensuring adherence to Carelon MBM's unique clinical guidelines and appeal pathways, distinct from standard Anthem medical policies.

Pharmacy Prior Authorizations via CarelonRx and ePA Partners

Pharmacy prior authorizations for Anthem-licensed plans are managed by CarelonRx (formerly IngenioRx). Klivira integrates with CarelonRx's provider PA system and ePA platforms like CoverMyMeds and Surescripts to automate retail pharmacy PA requests. This includes common categories such as GLP-1s and other high-cost biologics, ensuring prescribers can initiate and track pharmacy PAs efficiently, minimizing delays in medication access.

Policy Access and Turnaround Time Considerations for Anthem

Anthem operating companies publish medical policies and clinical guidelines via provider sites accessed through Availity, while Carelon MBM maintains its own guidelines for in-scope services. Klivira helps manage the complexity of these diverse policy sources. Furthermore, Klivira supports compliance with state-mandated turnaround times for commercial plans and CMS-0057-F requirements for Medicare Advantage and Medicaid managed-care plans, ensuring timely decision-making.