MatrixCare Anthem (Elevance Health) Prior Authorization Automation

Klivira delivers robust MatrixCare Anthem (Elevance Health) prior authorization automation, specifically engineered to meet the unique demands of long-term care, home health, and hospice providers utilizing MatrixCare.

For facilities operating on MatrixCare, navigating the complex and varied prior authorization requirements of Anthem-licensed plans from Elevance Health can significantly strain revenue cycle operations. Manual processes across multiple portals and channels lead to delays, increased administrative burden, and potential revenue loss. Klivira addresses these challenges by integrating directly with your EMR and connecting to Anthem's diverse submission pathways.

Connecting MatrixCare to Anthem's Diverse PA Channels

Anthem-licensed plans, under the Elevance Health umbrella, leverage multiple channels for prior authorization submissions. Klivira integrates with MatrixCare via MatrixCare APIs to automate data exchange, directing requests to the appropriate Anthem channel, whether it's through Availity Essentials for medical benefit PAs and X12 278 transactions, CarelonRx's ePA partners like CoverMyMeds and Surescripts for pharmacy benefits, or the specialized Carelon Medical Benefits Management portal for advanced imaging, cardiology, MSK, sleep, and radiation oncology.

Streamlining Utilization Management for Long-Term Care and Post-Acute Services

MatrixCare users in long-term care, home health, and hospice frequently manage complex patient populations requiring a range of services from specialty medications to advanced diagnostics. Klivira centralizes access to Anthem's state-specific medical policies and clinical utilization management guidelines, accessible via Availity, and Carelon MBM's specific guidelines. This ensures that prior authorization requests are aligned with criteria, whether Anthem-developed, Carelon-developed, MCG-based, or NCCN-compendium-based, reducing denials related to medical necessity or insufficient documentation.

Addressing CMS-0057-F Compliance for Anthem Plans

For Anthem's Medicare Advantage, Medicaid managed-care (under Anthem Medicaid plans and Wellpoint), CHIP managed-care, and QHP-on-FFM lines, the CMS-0057-F rule mandates specific turnaround times (72-hour standard, 24-hour expedited). Klivira's automation platform helps MatrixCare users meet these critical deadlines by accelerating submission and tracking, ensuring compliance and improving patient access to care in these regulated segments.

Optimizing Workflows for Specialty Drugs and Site-of-Care Policies

Given the prevalence of chronic conditions in long-term and post-acute care, MatrixCare providers often manage patients requiring specialty injectables and infusions. Anthem's active site-of-care policies and clinical indication criteria for these medical-benefit drugs, some routed through Carelon, introduce additional complexity. Klivira's platform helps manage these specific workflows, ensuring accurate submission and reducing denials often associated with site-of-service mismatches or non-formulary pharmacy claims.

Key Benefits of Klivira for MatrixCare and Anthem (Elevance Health) PA

Automated data extraction from MatrixCare via APIs for Anthem PA submissions.
Intelligent routing to Availity, X12 278, Carelon MBM, and ePA partners.
Proactive alerts for state-specific policy requirements and payer-published service-level targets.
Streamlined appeals processes for both Anthem operating companies and Carelon MBM denials.
Enhanced compliance with CMS-0057-F for impacted Anthem lines of business.
Reduced manual effort and improved prior authorization turnaround times.

Frequently asked questions

How does Klivira integrate with MatrixCare for Anthem prior authorizations?

Klivira integrates directly with MatrixCare using its robust MatrixCare APIs. This allows for automated, secure data exchange, pulling necessary patient and clinical information to populate prior authorization requests for submission to Anthem-licensed plans.

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

Klivira supports all primary Anthem prior authorization channels, including Availity Essentials for medical PAs and X12 278 transactions, CarelonRx's ePA partners (CoverMyMeds, Surescripts) for pharmacy PAs, and the Carelon Medical Benefits Management portal for specialized services like advanced imaging and cardiology.

Does Klivira help MatrixCare users comply with CMS-0057-F for Anthem plans?

Yes, Klivira assists MatrixCare users in complying with CMS-0057-F for Anthem's Medicare Advantage, Medicaid managed-care, CHIP, and QHP-on-FFM plans. By automating submission and tracking, Klivira helps ensure adherence to the mandated 72-hour standard and 24-hour expedited prior authorization decision timeframes.

How does Klivira handle prior authorizations managed by Carelon Medical Benefits Management for Anthem?

For services under Carelon Medical Benefits Management (e.g., advanced imaging, MSK), Klivira intelligently routes prior authorization requests directly to the Carelon MBM provider portal. This ensures that these specialized requests follow the correct submission and appeal pathways, distinct from general medical PAs.

Can Klivira help with Anthem's site-of-care policies for specialty drugs relevant to MatrixCare providers?

Yes, Klivira's platform is designed to manage the complexities of Anthem's site-of-care and clinical-indication policies for specialty drugs on the medical benefit. It helps ensure that prior authorization requests from MatrixCare align with these specific criteria, reducing denials related to inappropriate service settings.