Optimizing PointClickCare Anthem (Elevance Health) Prior Authorization Automation

The PointClickCare-Anthem Prior Authorization Challenge

Long-term care and senior living facilities using PointClickCare face unique prior authorization hurdles when dealing with Anthem-licensed plans. The need for precise documentation for extended stays, specific therapies, or specialty medications, combined with Anthem's multi-channel submission landscape, often creates bottlenecks. Klivira addresses this by automating the submission process, ensuring requests align with payer-specific requirements and reducing administrative overhead.

Klivira's Integration with PointClickCare

Klivira integrates directly with PointClickCare via its robust APIs, enabling seamless data exchange for prior authorization requests. This direct connection allows for the automated extraction of necessary patient demographics, clinical documentation, and service codes from the EMR, minimizing manual data entry and potential errors. Facilities can initiate and track Anthem PAs without leaving their native PointClickCare environment.

Navigating Anthem's Multi-Channel Submission Landscape

Anthem (Elevance Health) utilizes various channels for prior authorization submissions, each with specific requirements. Klivira's platform is engineered to navigate these complexities, ensuring requests are routed correctly and efficiently.

Key Anthem Prior Authorization Channels Supported:

• Medical benefit PA submissions via Availity Essentials and X12 278 transactions for commercial and Medicare Advantage plans.
• Pharmacy benefit PA routing through CarelonRx's provider system, CoverMyMeds, and Surescripts ePA for prescriber-initiated workflows.
• Specialty services (advanced imaging, cardiology, MSK, sleep, radiation oncology) submitted directly to the Carelon Medical Benefits Management provider portal.
• Behavioral health services managed through Carelon Behavioral Health, with carve-out considerations per line of business.
• Specialty injectables and infusions on the medical benefit, adhering to Anthem's site-of-care and clinical-indication policies.

Streamlining Utilization Management and Policy Adherence

Effective prior authorization requires strict adherence to payer medical policies and clinical guidelines. Klivira helps facilities stay current with Anthem's utilization management criteria, accessing medical-policy and clinical-UM-guideline libraries published through provider sites via Availity. For procedures routed through Carelon Medical Benefits Management, Klivira ensures guidelines are referenced from the Carelon MBM provider site, aligning submissions with the correct criteria. This includes considerations for CMS-0057-F impacting Anthem's Medicare Advantage, Medicaid, and QHP lines of business.

Impact on Long-Term and Senior Care Workflows

For PointClickCare users in skilled nursing facilities (SNFs) and senior living, Klivira's automation translates into faster PA approvals for critical services. This includes therapies, extended stays, and access to specialty medications often vital for this patient population. By reducing manual effort and improving submission accuracy, facilities can enhance patient care continuity, optimize resource allocation, and accelerate revenue cycles by minimizing denials related to prior authorization.