CureMD Anthem (Elevance Health) Prior Authorization Automation

Streamlining Anthem's Diverse Prior Authorization Channels from CureMD

Anthem (Elevance Health) operating companies utilize a multi-pronged approach for prior authorization submissions, which can be a significant operational hurdle for CureMD users. Klivira automates submissions across these critical channels. For medical benefit PAs, Klivira connects to Anthem's primary multi-payer provider workspace, Availity Essentials, and supports X12 278 transactions via clearinghouses. Pharmacy benefit PAs, routed through CarelonRx, are handled via ePA partners like CoverMyMeds and Surescripts.

Automating Specialty-Specific Workflows with Carelon Medical Benefits Management

For specialized services such as advanced imaging, cardiology, musculoskeletal care, sleep studies, and radiation oncology, Anthem-licensed plans direct prior authorizations through Carelon Medical Benefits Management (formerly AIM Specialty Health). This requires a distinct submission pathway and policy adherence. Klivira integrates directly with the Carelon MBM provider portal, ensuring that PAs for these specific domains are routed correctly and efficiently, separate from standard medical PAs, reducing manual intervention and potential errors for CureMD users.

Klivira's Seamless Integration with CureMD EHR

Klivira's platform integrates with CureMD via the CureMD API, enabling a direct and secure exchange of patient data and clinical documentation. This integration eliminates the need for manual chart abstraction and dual data entry, allowing your prior authorization coordinators to initiate and manage PAs without leaving the CureMD environment. By leveraging the CureMD API, Klivira ensures that all necessary clinical context is automatically populated for Anthem submissions, enhancing accuracy and speed.

Proactive Compliance and Policy Adherence for Anthem Plans

Anthem operating companies publish comprehensive medical policies and clinical utilization management guidelines, accessible through provider sites via Availity. For services routed through Carelon MBM, specific guidelines are available on the Carelon MBM provider site. Klivira's automation engine helps ensure that submitted prior authorizations align with these criteria, referencing whether they are Anthem-developed, Carelon-developed, MCG-based, or NCCN-compendium-based. Furthermore, Klivira supports compliance with federal mandates like CMS-0057-F for Anthem's Medicare Advantage and Medicaid managed-care plans, helping meet expedited and standard decision timeframes.

Key Benefits of Klivira for CureMD + Anthem PA Automation

• Automated submission to Anthem via Availity, Carelon MBM, X12 278, and ePA partners.
• Direct integration with CureMD API for seamless data exchange and reduced manual effort.
• Enhanced accuracy and completeness of PA requests, minimizing denials due to insufficient documentation.
• Accelerated turnaround times for critical services, including specialty imaging and biologics.
• Improved adherence to state-specific regulations and CMS-0057-F compliance for applicable plans.
• Centralized tracking and real-time status updates for all Anthem prior authorizations.

Optimizing Denial Management and Appeals for Anthem (Elevance Health)

Anthem denials are communicated via X12 277/835 transactions and Availity status updates, often citing reasons such as medical necessity, step therapy, or site-of-service mismatch. Klivira helps identify common denial patterns and provides insights for more effective resubmissions. For procedures managed by Carelon MBM, a separate appeals process is in place. Klivira assists in organizing documentation for both Anthem and Carelon-managed appeals, supporting your team through the peer-to-peer review process and formal appeal pathways to recover revenue.