Evolved Digital Health Centene Prior Authorization Automation

Klivira delivers comprehensive Evolved Digital Health Centene prior authorization automation, empowering specialty practices to navigate Centene's complex payer ecosystem with efficiency and precision.

For revenue cycle directors and prior authorization coordinators utilizing Evolved Digital Health, managing Centene's diverse portfolio of Medicaid managed care, ACA marketplace (Ambetter), and Medicare Advantage (WellCare, Allwell) plans presents unique challenges. Klivira directly addresses these complexities, transforming manual PA workflows into a streamlined, integrated process.

The Challenge: Evolved Digital Health to Centene Prior Authorization

Specialty practices relying on Evolved Digital Health often face significant administrative burden when submitting prior authorizations to Centene. Given Centene's federated structure, with numerous state-specific subsidiaries (e.g., Fidelis Care, Health Net, Meridian, Sunshine Health) and national brands, navigating varied portals, policies, and submission requirements can lead to delays, increased denial rates, and staff burnout.

Seamless Integration with Evolved Digital Health

Klivira connects directly with Evolved Digital Health via its robust Evolved APIs, embedding prior authorization workflows within your existing clinical and administrative environment. This integration eliminates the need for manual data entry into separate systems, pulling necessary patient demographics, clinical documentation, and order details directly from the EMR to initiate PA requests.

Navigating Centene's Federated Payer Ecosystem

Centene's operational model means providers interact with subsidiary-specific portals for medical PA, while pharmacy PAs often route through Envolve Pharmacy Solutions, CoverMyMeds, or Surescripts ePA. Klivira intelligently directs prior authorization requests to the appropriate Centene subsidiary, brand (Ambetter, WellCare), or channel, whether it's an X12 278 transaction via a clearinghouse or an electronic submission to a specific portal or ePA platform.

Streamlining Key Prior Authorization Workflows for Specialty Care

Klivira's platform is designed to manage the full spectrum of prior authorization requirements prevalent in specialty care, critical for Evolved Digital Health users. This includes complex medical-benefit specialty drugs, advanced imaging, surgical procedures, and behavioral health services often managed by Centene Behavioral Health. Our system adapts to the specific criteria and submission pathways for each service line and Centene entity.

Automating Policy Adherence and Turnaround Time Compliance

Centene subsidiaries publish their own clinical policies, often leveraging InterQual criteria or NCCN compendium for oncology. For Medicaid lines, state Medicaid agency rules always take precedence. Klivira helps ensure PA requests align with the relevant subsidiary's specific policies and state-mandated turnaround times for Medicaid, Medicare Advantage (CMS-0057-F compliant), and Ambetter plans, significantly reducing 'insufficient documentation' denials.

Key Benefits for Evolved Digital Health Users

Direct integration with Evolved APIs for automated data extraction.
Intelligent routing to the correct Centene subsidiary portal or electronic channel.
Real-time status updates and denial reason tracking via X12 277/835.
Support for both medical and pharmacy benefit prior authorizations.
Streamlined workflows for complex specialty medications and procedures.
Enhanced compliance with state and federal PA regulations, including CMS-0057-F.

Frequently asked questions

How does Klivira integrate with Evolved Digital Health for prior authorizations?

Klivira integrates directly with Evolved Digital Health using its robust Evolved APIs. This allows for automated extraction of patient demographics, clinical notes, and order details, populating prior authorization requests without manual data transfer.

Can Klivira handle prior authorizations for all Centene brands like Ambetter and WellCare?

Yes, Klivira supports prior authorizations across Centene's diverse portfolio, including Ambetter (ACA marketplace plans), WellCare (Medicare plans), Allwell (Medicare Advantage), and all state-specific Medicaid managed care subsidiaries. Our system routes requests to the appropriate entity and channel.

Does Klivira help with Centene's varied policy requirements and turnaround times?

Klivira streamlines adherence to Centene's subsidiary-specific policies, which often incorporate InterQual or NCCN criteria. We also help manage compliance with diverse turnaround timeframes, including state Medicaid mandates, Medicare Advantage statutory rules, and the requirements of CMS-0057-F.

What channels does Klivira use to submit PAs to Centene?

Klivira utilizes various channels depending on the Centene entity and service. This includes subsidiary-specific provider portals, X12 278 transactions via clearinghouses, and electronic pharmacy PA platforms like CoverMyMeds and Surescripts through Envolve Pharmacy Solutions.

Is Klivira suitable for specialty practices using Evolved Digital Health?

Absolutely. Given Evolved Digital Health's specialty focus, Klivira is particularly well-suited for these practices. We automate prior authorizations for complex specialty medications, advanced diagnostics, and procedures that are common in specialty care and often require Centene's review.