Streamlining Optum Physician Anthem (Elevance Health) Prior Authorization Automation

Klivira automates prior authorization workflows for Optum Physician-affiliated ambulatory practices facing Anthem (Elevance Health) requirements, integrating directly with your underlying EMR.

Navigating prior authorizations for Anthem (Elevance Health) patients within an Optum Physician-affiliated practice presents unique challenges. The complexity of diverse submission channels, coupled with the need to integrate seamlessly with your core EMR, often leads to administrative burden and delayed care. Klivira addresses these operational pain points by streamlining the entire PA lifecycle.

Integrating Klivira with Optum Physician-Affiliated EMRs

Klivira's platform integrates with the underlying EMR systems commonly used by Optum Physician-affiliated ambulatory practices, such as Epic, Cerner, or athena. This approach ensures that prior authorization requests originate directly from the clinical record, leveraging existing EMR APIs and SMART on FHIR capabilities where available, rather than relying on an Optum-proprietary overlay. This direct integration minimizes disruption to established clinical workflows.

Navigating Anthem (Elevance Health) Prior Authorization Channels

Anthem (Elevance Health) utilizes a multi-channel approach for prior authorization submissions, which Klivira's platform is engineered to manage. For medical benefit PAs, submissions are typically routed through Availity Essentials or via X12 278 transactions. Pharmacy benefit PAs, managed by CarelonRx, leverage ePA partners like CoverMyMeds and Surescripts for prescriber-initiated requests.

Key Prior Authorization Workflows Automated for Anthem (Elevance Health)

Medical benefit prior authorizations submitted via Availity Essentials for general procedures and services.
X12 278 electronic submissions for medical necessity reviews through clearinghouses.
Pharmacy prior authorizations for retail and specialty medications through CarelonRx, leveraging CoverMyMeds and Surescripts ePA.
Prior authorizations for advanced imaging, cardiology, and musculoskeletal services routed through Carelon Medical Benefits Management's dedicated portal.
Inpatient admission notifications and concurrent review requests processed via Availity.

Addressing Complex Specialty and Site-of-Care Policies

Optum Physician practices frequently manage complex patient populations, including those requiring specialty drugs or advanced procedures. Anthem (Elevance Health) implements specific site-of-care policies and clinical guidelines for specialty injectables, infusions, and certain high-cost therapies. Klivira helps manage these nuanced requirements by connecting to Anthem's policy libraries, including those for Carelon Medical Benefits Management, to ensure submissions align with current medical necessity criteria and avoid common denial patterns.

Optimizing Turnaround Times and Compliance

Klivira's automation platform is designed to optimize prior authorization turnaround times for Anthem (Elevance Health) requests, facilitating compliance with state-specific regulations and federal mandates like CMS-0057-F for Medicare Advantage and Medicaid lines. By automating submission, tracking, and status updates, practices can reduce manual delays and expedite patient access to care, while ensuring the necessary documentation is provided promptly.

Frequently asked questions

How does Klivira integrate with my Optum Physician practice's EMR for Anthem PAs?

Klivira integrates directly with the core EMR system used by your Optum Physician-affiliated practice, such as Epic or Cerner. This allows prior authorization data to flow seamlessly from the patient chart to Klivira's platform, then to Anthem (Elevance Health) via the appropriate channel, without requiring redundant data entry or navigating multiple systems.

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

Klivira supports all primary Anthem (Elevance Health) prior authorization channels, including medical benefit submissions through Availity Essentials and X12 278, pharmacy benefit ePA via CoverMyMeds and Surescripts (for CarelonRx), and specialty benefit management requests routed through Carelon Medical Benefits Management's dedicated portals.

Can Klivira help with prior authorizations for advanced imaging or specialty drugs from Anthem?

Yes, Klivira is configured to handle complex prior authorizations for services like advanced imaging, cardiology, and musculoskeletal procedures that route through Carelon Medical Benefits Management. It also supports specialty drug PAs, navigating Anthem's specific medical benefit and pharmacy benefit policies to ensure accurate and timely submissions.

How does Klivira address the different state-specific Anthem policies?

Klivira's platform helps practices navigate the varying medical policies and clinical guidelines published by Anthem's state-licensed plans. By providing a structured workflow for documentation and submission, it supports adherence to the specific criteria and turnaround timeframes applicable to each patient's Anthem (Elevance Health) plan.

Does Klivira integrate with OptumRx for pharmacy benefits?

While OptumRx is a distinct entity, Klivira's integration with the underlying EMR facilitates the submission of pharmacy prior authorizations to Anthem's PBM, CarelonRx. This includes leveraging ePA partners like CoverMyMeds and Surescripts, ensuring comprehensive coverage of pharmacy benefit PA workflows.