Practice Fusion Anthem (Elevance Health) Prior Authorization Automation

Klivira delivers end-to-end Practice Fusion Anthem (Elevance Health) prior authorization automation, streamlining a complex, multi-channel payer landscape directly from your EMR.

For practices utilizing Practice Fusion, navigating the diverse prior authorization requirements of Anthem-licensed plans (part of Elevance Health) can introduce significant administrative overhead. From medical benefit PAs via Availity to pharmacy PAs through CarelonRx and specialty services managed by Carelon Medical Benefits Management, manual processes fragment workflows and strain resources. Klivira addresses this by centralizing and automating these critical steps.

Navigating Anthem Prior Authorization Channels from Practice Fusion

Anthem, operating under Elevance Health, employs a multi-faceted approach to prior authorization submissions. Medical PAs for commercial and Medicare Advantage plans are typically routed through Availity Essentials, while pharmacy benefit PAs leverage CarelonRx's systems and ePA partners like CoverMyMeds and Surescripts. Specialty services such as advanced imaging, cardiology, and MSK are managed by Carelon Medical Benefits Management, requiring separate portal submissions. Klivira ensures your Practice Fusion-initiated requests are directed to the correct Anthem channel.

Seamless Integration with Practice Fusion via FHIR API

Klivira integrates with Practice Fusion by leveraging its FHIR API, enabling a direct flow of patient and clinical data necessary for prior authorization. This robust connection minimizes manual data entry, reduces context switching, and ensures that critical patient information from the Practice Fusion chart is accurately and efficiently used to populate Anthem PA requests, aligning with the EMR's web-based architecture.

Key Anthem Prior Authorization Submission Pathways Supported:

Medical benefit PAs for commercial and Medicare Advantage plans via Availity Essentials, including X12 278 transactions.
Pharmacy benefit PAs through CarelonRx's system and ePA partners like CoverMyMeds and Surescripts.
Specialty services (e.g., advanced imaging, cardiology, MSK, sleep, radiation oncology) managed by Carelon Medical Benefits Management.
Inpatient admission notifications and concurrent review intake via Availity.
Specialty drug PAs on the medical benefit, routed to the appropriate Anthem or Carelon channel.

Optimizing Workflows for Diverse Anthem Service Lines

Whether it's a medical necessity review for a surgical procedure, an imaging study requiring Carelon Medical Benefits Management approval, or a specialty medication requiring pharmacy benefit PA, Klivira adapts. Our platform intelligently identifies the correct submission channel and required documentation based on Anthem's specific policies, streamlining the process for Practice Fusion users across all service lines, from primary care to specialty referrals.

Navigating Anthem Policy and Compliance Considerations

Anthem-licensed plans are subject to varied regulatory requirements, including state-specific commercial PA timeframes and federal mandates like CMS-0057-F for Medicare Advantage, Medicaid managed care, and QHP lines. Klivira assists in managing these complexities by facilitating timely submissions and tracking. Access to Anthem medical policies and Carelon Medical Benefits Management clinical guidelines is critical; these are available through Availity and the Carelon MBM provider portal, respectively, allowing for evidence-grounded PA submissions.

Frequently asked questions

How does Klivira integrate with Practice Fusion for Anthem prior authorizations?

Klivira integrates with Practice Fusion primarily through its FHIR API, allowing for the secure and efficient exchange of patient demographics and clinical data. This integration automates the extraction of necessary information to populate Anthem prior authorization requests, reducing manual data entry for Practice Fusion users.

Which Anthem prior authorization channels does Klivira support?

Klivira supports a comprehensive range of Anthem prior authorization channels. This includes submissions to Availity Essentials for medical benefits, integration with CarelonRx's ePA partners (CoverMyMeds, Surescripts) for pharmacy benefits, and routing to Carelon Medical Benefits Management for specialty services like advanced imaging and MSK.

Does Klivira help with pharmacy benefit prior authorizations for Anthem?

Yes, Klivira automates pharmacy benefit prior authorizations for Anthem-licensed plans, which are managed by CarelonRx. Our platform integrates with ePA partners such as CoverMyMeds and Surescripts to streamline the submission process for prescribers using Practice Fusion.

How does Klivira handle Anthem's specialty benefit management (Carelon Medical Benefits Management) PAs?

For services managed by Carelon Medical Benefits Management (formerly AIM Specialty Health), such as advanced imaging or cardiology, Klivira ensures that prior authorization requests are correctly routed to the Carelon MBM provider portal. This specialized routing ensures compliance with Elevance Health's specific clinical guidelines for these domains.

What compliance considerations are important for Anthem prior authorizations?

Key compliance considerations for Anthem PAs include adherence to state-mandated turnaround times for commercial plans and the phased compliance timelines of CMS-0057-F for Medicare Advantage and Medicaid plans. Klivira helps manage these by facilitating timely submissions and providing visibility into PA status, supporting your practice's compliance efforts.