MicroMD Anthem (Elevance Health) Prior Authorization Automation

Navigating Anthem's Diverse Prior Authorization Channels from MicroMD

Anthem, operating under Elevance Health, presents a complex prior authorization ecosystem. Submissions for medical benefits often route through Availity Essentials, while specific specialty benefits like advanced imaging, cardiology, or MSK services are managed by Carelon Medical Benefits Management. Pharmacy benefit prior authorizations, including for retail drugs, are handled by CarelonRx and its ePA partners like CoverMyMeds and Surescripts. Klivira's platform is engineered to manage these distinct pathways, ensuring MicroMD users can initiate and track prior authorizations through the correct Anthem channel.

Key Anthem (Elevance Health) Prior Authorization Submission Pathways

• **Availity Essentials:** Primary channel for commercial and Medicare Advantage medical benefit PAs, including X12 278 transactions.
• **Carelon Medical Benefits Management:** Dedicated portal for advanced imaging, cardiology, musculoskeletal, sleep, and radiation oncology PAs.
• **CarelonRx (CoverMyMeds/Surescripts):** Electronic prior authorization for retail pharmacy benefits.
• **Carelon Behavioral Health:** Manages behavioral health services for many Anthem lines, requiring careful verification of carve-out status.
• **Direct Medical Benefit Policies:** For specialty injectables and infusions, often subject to Anthem's site-of-care and clinical-indication policies.

Seamless Integration with MicroMD for Anthem PA Workflows

Klivira integrates with Henry Schein MicroMD via its robust MicroMD APIs, creating a unified prior authorization workflow. This integration allows clinical and administrative staff to initiate, track, and manage Anthem prior authorizations without leaving the familiar MicroMD interface. By minimizing context switching and manual data entry, Klivira enhances efficiency and reduces the potential for errors inherent in multi-portal PA processes.

Automating Specialty and Medical Benefit Prior Authorizations

For MicroMD users, automating prior authorizations for Anthem's specialty drug policies or advanced imaging requests routed through Carelon Medical Benefits Management is critical. Klivira's platform intelligently routes requests to the appropriate Anthem channel, whether it's an X12 278 transaction for a surgical procedure, an ePA for a specialty medication like a biologic, or a submission through the Carelon MBM portal for a cardiac MRI. This ensures adherence to specific payer requirements and accelerates decision times.

Proactive Policy Guidance and Turnaround Time Management

Klivira's automation platform helps MicroMD users navigate Anthem's utilization management policies, which are published through Availity-accessed provider sites. For procedures under Carelon Medical Benefits Management, guidelines are found on the Carelon MBM provider site. The system also assists in tracking state-mandated turnaround times and payer-published service-level targets, particularly for Anthem's Medicare Advantage, Medicaid, and QHP lines impacted by CMS-0057-F's 72-hour (standard) and 24-hour (expedited) decision timeframes.

Optimizing for Anthem Denial Patterns and Appeals

Anthem denials, often returned via X12 277/835 transactions or Availity status updates, commonly cite medical necessity, step therapy, or site-of-service mismatch. Klivira helps pre-empt these issues by providing real-time policy checks and ensuring complete documentation. In the event of a denial, the platform streamlines the appeals process, connecting MicroMD users to the appropriate Anthem operating-company appeal pathway or the separate Carelon Medical Benefits Management appeal process, facilitating peer-to-peer reviews.