Evolved Digital Health Anthem (Elevance Health) Prior Authorization Automation

Klivira's Integration with Evolved Digital Health

Klivira leverages Evolved Digital Health's APIs to establish a direct, secure connection, enabling bidirectional data flow for prior authorization requests. This integration minimizes manual data entry, pulls necessary clinical documentation directly from the EMR, and posts status updates back into the Evolved EHR, maintaining a single source of truth for patient records.

Navigating Anthem (Elevance Health) Prior Authorization Workflows

Anthem, operating as a multi-state Blue Cross Blue Shield licensee under parent Elevance Health, presents a complex prior authorization landscape. Submissions often involve multiple channels depending on benefit type, service line, and state-specific regulations. Klivira centralizes these disparate pathways, providing a unified workflow for your Evolved Digital Health users.

Key Anthem (Elevance Health) Prior Authorization Submission Channels

• **Availity Essentials:** Primary multi-payer provider workspace for commercial and Medicare Advantage medical benefit PA, including inpatient admission notifications.
• **X12 278 Transactions:** Supported for medical benefit prior authorizations via clearinghouses, offering an electronic data interchange pathway.
• **Carelon Medical Benefits Management Portal:** Dedicated for advanced imaging, cardiology, musculoskeletal (MSK), sleep, and radiation oncology services.
• **CoverMyMeds & Surescripts ePA:** For retail pharmacy benefit prior authorizations managed by CarelonRx.
• **Carelon Behavioral Health:** For behavioral health services where managed separately; verify carve-out status per line of business and state.

Policy Access and Clinical Criteria for Anthem (Elevance Health)

Accessing the correct medical policies and clinical criteria is crucial for successful prior authorization. Anthem-licensed plans publish medical-policy and clinical-UM-guideline libraries via provider sites accessed through Availity, with state-specific variations. For services under Carelon Medical Benefits Management, guidelines are published directly on the Carelon MBM provider site, requiring distinct access. Klivira helps teams identify and apply the relevant criteria, whether Anthem-developed, Carelon-developed, MCG-based, or NCCN-compendium-based for oncology.

Optimizing Specialty-Specific Prior Authorizations

Given Evolved Digital Health's focus on specialty practices, Klivira's automation is particularly valuable for Anthem's specialty drug and specialty service PA requirements. This includes navigating site-of-care policies for specialty injectables and infusions, as well as managing authorizations for procedures routed through Carelon Medical Benefits Management, ensuring clinical documentation aligns with payer-specific criteria and addressing common denial patterns like site-of-service mismatch.

Accelerating Prior Authorization Decisions with Klivira

Klivira helps accelerate the prior authorization lifecycle by ensuring accurate, complete submissions. For Anthem's Medicare Advantage and Medicaid managed-care plans, Klivira supports compliance with CMS-0057-F requirements for 72-hour standard and 24-hour expedited decision timeframes. While commercial turnaround times are governed by state insurance regulations, Klivira's efficient submission process reduces common delays.

Streamlining Denials and Appeals for Anthem (Elevance Health)

Klivira facilitates the management of prior authorization denials by providing clear visibility into denial reasons, which are typically returned via X12 277/835 transactions and Availity status updates. Common denial categories for Anthem include medical necessity, step therapy not completed, and site-of-service mismatch. For Carelon Medical Benefits Management denials, Klivira supports routing to the separate Carelon-managed appeals process, including peer-to-peer review initiation.