Streamlining eMDs Anthem (Elevance Health) Prior Authorization Automation

Klivira streamlines eMDs Anthem (Elevance Health) prior authorization automation, reducing manual effort and accelerating approvals for ambulatory practices.

Ambulatory practices utilizing eMDs face significant administrative burdens when managing prior authorizations for Anthem (Elevance Health) plans. The complexity of Anthem's diverse submission channels—from Availity to specialty benefit managers and ePA partners—demands a robust, integrated solution. Klivira bridges this gap, providing comprehensive automation that integrates directly with your eMDs environment.

Seamless Integration with eMDs for Anthem Prior Authorizations

Klivira integrates with eMDs (CompuGroup Medical's ambulatory EHR) via CGM APIs. This direct connection facilitates the secure extraction of necessary patient demographic, clinical, and encounter data, populating prior authorization requests automatically. By embedding Klivira into your eMDs workflow, your prior authorization coordinators can initiate requests without redundant data entry, maintaining data integrity and reducing errors.

Navigating Anthem's Multi-Channel Prior Authorization Landscape

Anthem (Elevance Health) utilizes a multi-pronged approach for prior authorization submissions, which Klivira consolidates. Medical benefit prior authorizations for commercial and Medicare Advantage plans are primarily routed through Availity Essentials, or via X12 278 transactions through clearinghouses. Pharmacy benefit prior authorizations, managed by CarelonRx, leverage ePA partners like CoverMyMeds and Surescripts. For specialized services such as advanced imaging, cardiology, and radiation oncology, requests are directed through Carelon Medical Benefits Management's dedicated portal.

Optimizing Workflows for Key Service Lines and Specialty Drugs

Klivira's automation is tailored to address the specific prior authorization requirements across Anthem's diverse service lines. For advanced imaging and other services managed by Carelon MBM, Klivira ensures requests are routed correctly and clinical guidelines are referenced from the Carelon MBM provider site. For specialty injectables and infusions on the medical benefit, Klivira helps navigate Anthem's site-of-care and clinical-indication policies, streamlining submissions for complex therapeutic categories.

Accessing Anthem Medical Policies and Clinical Guidelines

Access to accurate, up-to-date medical policies is critical. Anthem operating companies publish medical policies and clinical utilization management guidelines via provider sites accessible through Availity, with state-specific Medicaid and Medicare Advantage variants. For procedures managed by Carelon Medical Benefits Management, their specific clinical guidelines are published on the Carelon MBM provider site. Klivira aids in centralizing the access and application of these diverse criteria to ensure submitted requests are aligned with payer requirements.

Addressing Regulatory Considerations for Anthem PA

Anthem's Medicare Advantage, Medicaid managed-care (under Anthem Medicaid plans and Wellpoint), CHIP managed-care, and QHP-on-FFM lines are impacted payers under CMS-0057-F. This mandates specific 72-hour standard and 24-hour expedited PA decision timeframes. Klivira's platform helps track these critical timelines, ensuring compliance and enabling proactive follow-up for these regulated plan types. Commercial PA timeframes are governed by state insurance regulations, which vary materially across Anthem's operating states.

Frequently asked questions

How does Klivira integrate with eMDs for Anthem prior authorizations?

Klivira integrates with eMDs via CGM APIs to securely extract patient data, clinical notes, and other relevant information directly from the EHR. This enables automated population of prior authorization requests, reducing manual data entry and ensuring accuracy for submissions to Anthem.

Which Anthem prior authorization submission channels does Klivira support?

Klivira supports Anthem's primary medical PA channels, including Availity and X12 278 transactions. For pharmacy PAs, Klivira integrates with ePA partners like CoverMyMeds and Surescripts. Additionally, Klivira facilitates submissions to Carelon Medical Benefits Management for specialty benefit services like advanced imaging.

Can Klivira help with prior authorizations for services managed by Carelon Medical Benefits Management?

Yes, Klivira streamlines prior authorizations for services under Carelon Medical Benefits Management (formerly AIM Specialty Health), such as advanced imaging, cardiology, and MSK. Klivira ensures requests are routed to the correct Carelon MBM portal and helps apply the relevant clinical guidelines for these specific domains.

Does Klivira assist with pharmacy prior authorizations for Anthem plans?

Yes, for Anthem plans served by CarelonRx (formerly IngenioRx), Klivira supports pharmacy prior authorization workflows. This includes integration with ePA partners like CoverMyMeds and Surescripts, enabling prescribers to initiate and track retail pharmacy PA requests efficiently.

How does Klivira help monitor the status of Anthem prior authorizations?

Klivira centralizes the tracking of Anthem prior authorization statuses, whether submitted via Availity, X12 278, or specialty portals. The platform provides real-time updates and notifications, allowing your team to proactively manage requests, identify bottlenecks, and adhere to state-specific and CMS-0057-F mandated turnaround times.