DrChrono Anthem (Elevance Health) Prior Authorization Automation

Klivira delivers robust DrChrono Anthem (Elevance Health) prior authorization automation, optimizing workflows for ambulatory and concierge practices. Our platform navigates the intricate PA landscape to accelerate approvals and reduce administrative overhead.

Managing prior authorizations for Anthem (Elevance Health) plans from within DrChrono presents unique challenges, particularly for small ambulatory and concierge practices. The diverse submission channels, varying policy access points, and complex benefit carve-outs demand a sophisticated approach to maintain revenue cycle integrity and ensure timely patient care. Klivira directly addresses these operational complexities.

Seamless Integration with DrChrono EHR

Klivira integrates directly with DrChrono using its robust API and FHIR endpoints, allowing prior authorization requests to be initiated from within the EMR. This eliminates manual data entry, reduces errors, and ensures that clinical documentation required for Anthem (Elevance Health) submissions is readily accessible, maintaining a single source of truth for patient information.

Navigating Anthem's Diverse Prior Authorization Channels

Anthem (Elevance Health) utilizes a multi-pronged approach for prior authorization submissions, requiring a platform capable of intelligent routing. Klivira automates submissions across these channels, including medical benefit PA via Availity Essentials and X12 278 transactions, pharmacy PA through CarelonRx, CoverMyMeds, and Surescripts ePA, and specialty benefit management through Carelon Medical Benefits Management (formerly AIM Specialty Health) for domains like advanced imaging and cardiology.

Key Prior Authorization Workflows Automated for DrChrono and Anthem

Medical benefit PA for commercial and Medicare Advantage plans via Availity and X12 278.
Pharmacy benefit PA for retail and specialty drugs through CarelonRx, CoverMyMeds, and Surescripts ePA.
Specialty imaging, cardiology, MSK, sleep, and radiation oncology PA routed through Carelon Medical Benefits Management's dedicated portal.
Medical benefit specialty drug PA, including site-of-care and clinical indication policies.
Behavioral health PA for services managed by Carelon Behavioral Health, where applicable.

Streamlined Access to Anthem and Carelon UM Policies

Accessing the correct utilization management criteria is critical for successful prior authorizations. Klivira centralizes access to Anthem's medical-policy and clinical-UM-guideline libraries, typically published on provider sites via Availity. For procedures managed by Carelon Medical Benefits Management, our system directs users to the specific clinical guidelines available on the Carelon MBM provider site, ensuring the most accurate criteria are applied.

Accelerating Approvals and Ensuring Compliance

Klivira helps practices meet payer turnaround timeframes and navigate compliance requirements. For Anthem's Medicare Advantage, Medicaid managed-care, CHIP, and QHP-on-FFM lines, Klivira supports adherence to CMS-0057-F mandates for decision timeframes. Our automation reduces manual effort, allowing your team to focus on clinical documentation and appeals rather than channel navigation.

Proactive Denial Management and Appeals

Anthem denials often stem from medical necessity, step therapy, or site-of-service mismatches. Klivira facilitates proactive denial management by providing clear visibility into denial reasons, returned via X12 277/835 transactions or Availity status updates. Our platform supports the initiation of appeals through the Anthem operating-company appeals process or the separate Carelon MBM appeal pathway for in-scope procedures, including peer-to-peer review requests.

Frequently asked questions

How does Klivira integrate with DrChrono for prior authorizations?

Klivira integrates with DrChrono via its robust API and FHIR endpoints, allowing for the seamless initiation of prior authorization requests directly from the EMR. This connection ensures that patient demographics, clinical notes, and order details are automatically populated into the PA request, reducing manual data entry and potential errors.

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

Klivira supports all major Anthem (Elevance Health) prior authorization channels. This includes submissions to Availity Essentials for medical benefit PAs, X12 278 transactions via clearinghouses, and electronic pharmacy PAs through CarelonRx, CoverMyMeds, and Surescripts. We also integrate with the Carelon Medical Benefits Management portal for specialty services like imaging and cardiology.

How does Klivira handle Anthem's specific medical policies and clinical guidelines?

Klivira provides streamlined access to Anthem's medical policies and clinical guidelines, typically found on provider sites accessed via Availity. For specialty services managed by Carelon Medical Benefits Management (e.g., advanced imaging), our system directs users to the specific guidelines published on the Carelon MBM provider site, ensuring the correct criteria are always referenced.

Does Klivira help with prior authorization turnaround times for Anthem plans?

Yes, Klivira's automation significantly accelerates the submission process, which helps practices meet or exceed Anthem's published precertification turnaround commitments. For Medicare Advantage and Medicaid plans, our platform supports adherence to the 72-hour standard and 24-hour expedited decision timeframes mandated by CMS-0057-F.

Can Klivira assist with appeals for Anthem (Elevance Health) prior authorization denials?

Klivira provides tools to manage Anthem prior authorization denials by capturing denial reasons from X12 277/835 transactions and Availity status updates. Our platform facilitates the initiation of appeals, guiding users through the appropriate Anthem operating-company appeals process or the separate Carelon MBM appeal pathway, including support for peer-to-peer reviews.