Jane Anthem (Elevance Health) Prior Authorization Automation

Navigating Anthem's Diverse Prior Authorization Channels from Jane App

Anthem (Elevance Health) operates a multi-faceted prior authorization ecosystem. For medical benefit PAs, commercial and Medicare Advantage plans primarily route through Availity Essentials, which serves as Anthem's multi-payer provider workspace. This includes X12 278 transactions via clearinghouses for impacted procedures, and Availity also facilitates inpatient admission notifications and concurrent review intake. Pharmacy benefit PAs, managed by CarelonRx, utilize their provider PA system or integrate with ePA partners like CoverMyMeds and Surescripts for prescriber-initiated workflows.

Addressing Specialty Benefit Management for Allied Health Services

For many allied health practices, services like advanced imaging, musculoskeletal (MSK) care, and physical therapy often fall under specialty benefit management. Carelon Medical Benefits Management (formerly AIM Specialty Health), an Elevance Health vendor, manages these domains. Klivira's integration accounts for these distinct pathways, directing submissions to Carelon MBM's dedicated provider portal when applicable, ensuring accurate routing beyond the standard medical-PA channel.

Klivira's Integration with Jane App via Jane API

Klivira integrates directly with Jane App through the Jane API, enabling a seamless flow of patient and clinical data required for prior authorization requests. This direct connection eliminates manual data entry, reducing errors and accelerating the initiation of PA requests from within the Jane App environment. For allied health practices, this means a more efficient workflow for common services requiring prior authorization, such as physical therapy, chiropractic care, and mental health services.

Streamlining Policy Access and Utilization Management Criteria

Accessing the correct utilization management criteria is critical. Anthem operating companies publish medical policies and clinical UM guidelines through provider sites accessed via Availity, with state-specific Medicaid and Medicare Advantage variants. For procedures routed through Carelon Medical Benefits Management (e.g., advanced imaging, MSK), their clinical guidelines are published on the Carelon MBM provider site, separate from the general Anthem medical-policy library. Klivira helps consolidate this information, guiding users to the appropriate source for the relevant procedure category.

Compliance Considerations for Anthem Prior Authorizations

Anthem's Medicare Advantage, Medicaid managed-care, CHIP managed-care, and QHP-on-FFM lines are impacted payers under CMS-0057-F, subject to specific decision timeframes (e.g., 72-hour standard, 24-hour expedited). Commercial PA timeframes are governed by state insurance regulations, which vary materially across states where Anthem-licensed plans operate. Klivira's platform is designed to align with these regulatory requirements, helping practices maintain compliance and track decision timelines.

Key Benefits of Klivira for Jane App and Anthem (Elevance Health) Workflows

• Automated submission to Availity Essentials and X12 278 channels for medical PAs.
• Direct routing to Carelon Medical Benefits Management for imaging and MSK-related services.
• Integration with CarelonRx and ePA partners (CoverMyMeds, Surescripts) for pharmacy benefit PAs.
• Reduced manual data entry through Jane API integration, improving accuracy and efficiency.
• Centralized tracking of PA statuses and decision timelines across all Anthem channels.
• Support for navigating diverse Anthem medical policies and Carelon MBM clinical guidelines.