Tebra Anthem (Elevance Health) Prior Authorization Automation

Klivira delivers robust Tebra Anthem (Elevance Health) prior authorization automation, integrating directly with your EMR to accelerate approvals and reduce administrative burden for your practice.

Revenue cycle leaders and prior authorization teams navigating the complexities of Anthem (Elevance Health) prior authorizations from Tebra (formerly Kareo) understand the administrative overhead involved. Manual workflows across multiple payer portals and EMR systems consume valuable staff time and delay patient care. Klivira streamlines these critical processes, connecting your Tebra environment directly to Anthem's diverse submission channels.

Seamless Integration: Tebra and Anthem (Elevance Health) Workflows

Klivira integrates with Tebra (including its former iterations like Kareo EHR and PatientPop) via the Tebra API, establishing a direct conduit for prior authorization data. This connection eliminates manual data entry, enabling automated submission of medical and pharmacy prior authorizations to Anthem-licensed plans, which operate under the Elevance Health corporate umbrella. Our platform intelligently routes requests to the appropriate Anthem channel, whether it's Availity Essentials, Carelon Medical Benefits Management, or ePA partners.

Automating Anthem Medical Benefit Prior Authorizations

For Anthem-licensed plans, medical benefit prior authorizations are primarily submitted through Availity Essentials, Anthem's multi-payer provider workspace, or via X12 278 transactions through clearinghouses. This includes a wide range of procedures, from inpatient admissions to complex surgical interventions. Klivira automates the extraction of necessary clinical documentation from Tebra and orchestrates submission through these channels, reducing the need for staff to manually navigate multiple portals for each request.

Navigating Specialty Services and Pharmacy Authorizations

Anthem's prior authorization landscape includes specialized pathways. Advanced imaging, cardiology, MSK, sleep, and radiation oncology services route through Carelon Medical Benefits Management (formerly AIM Specialty Health), requiring submission via their dedicated provider portal. For pharmacy benefit PAs, CarelonRx (rebranded from IngenioRx) manages retail pharmacy requests, often leveraging ePA partners like CoverMyMeds and Surescripts. Klivira accounts for these distinct pathways, ensuring each request reaches the correct Anthem (Elevance Health) entity with all required documentation.

Accessing Anthem Medical Policies and Utilization Management Criteria

Effective prior authorization requires precise adherence to payer medical policies and clinical guidelines. Anthem operating companies publish their medical policy and clinical UM guideline libraries through provider sites accessible via Availity. For domains managed by Carelon Medical Benefits Management, specific clinical guidelines are published on the Carelon MBM provider site. Klivira's integration facilitates the contextual application of these criteria, helping your team prepare compliant submissions and proactively address potential denial reasons like medical necessity or site-of-service mismatch.

Turnaround Times and Regulatory Compliance for Anthem (Elevance Health)

Anthem-licensed plans' commercial PA timeframes are governed by state-specific insurance regulations. For Medicare Advantage, Medicaid managed-care (under Anthem Medicaid plans and Wellpoint), CHIP, and QHP-on-FFM lines, Anthem is an impacted payer under CMS-0057-F. This rule mandates specific 72-hour standard and 24-hour expedited decision timeframes. Klivira's automation capabilities help practices manage these varied timelines by accelerating submission and tracking, supporting compliance with these critical regulatory requirements.

Frequently asked questions

How does Klivira integrate with Tebra for Anthem (Elevance Health) PAs?

Klivira integrates directly with Tebra (Kareo) via the Tebra API. This enables automated extraction of patient demographics, clinical notes, and order details, which are then used to populate and submit prior authorization requests to Anthem's various channels.

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

Klivira supports a comprehensive range of Anthem (Elevance Health) channels, including Availity Essentials for medical PAs, X12 278 for electronic submissions, Carelon Medical Benefits Management for specialty services (e.g., advanced imaging), and ePA partners like CoverMyMeds and Surescripts for pharmacy benefit requests through CarelonRx.

Can Klivira help with prior authorizations for specialty drugs covered by Anthem?

Yes, Klivira assists with specialty drug prior authorizations for Anthem-licensed plans. This includes both pharmacy benefit drugs routed through CarelonRx's ePA partners and specialty injectables/infusions on the medical benefit, navigating Anthem's site-of-care and clinical-indication policies.

How does Klivira address different medical policies from Anthem and Carelon MBM?

Klivira's system is designed to recognize and adapt to the distinct policy sources. It helps identify when to reference Anthem's state-specific medical policies (accessed via Availity) versus the specific clinical guidelines published on the Carelon Medical Benefits Management provider site for services under their scope.

Does Klivira help manage CMS-0057-F compliance for Anthem (Elevance Health) PAs?

Yes, for Anthem's Medicare Advantage and Medicaid managed-care plans, which are impacted by CMS-0057-F, Klivira's automation helps accelerate submission and tracking. This supports your team in meeting the mandated 72-hour standard and 24-hour expedited decision timeframes.