Anthem (Elevance Health) Epic Orchestrate: Optimizing Prior Authorization Workflows

Integrating Klivira with Epic Orchestrate provides a unified approach to managing prior authorizations for Anthem (Elevance Health) plans, centralizing disparate submission channels and policy requirements within the Epic environment.

Revenue cycle leaders and prior authorization coordinators face significant operational complexity when navigating the varied requirements of payers like Anthem. Epic Orchestrate offers a powerful framework for embedding automation and intelligent workflows directly within the EMR. Klivira enhances this by connecting Epic Orchestrate to Anthem's specific portals, ePA partners, and X12 278 channels, driving efficiency and reducing manual effort.

Navigating Anthem's Multi-Channel PA Landscape with Epic Orchestrate

Anthem-licensed plans, operating under Elevance Health, present a complex prior authorization ecosystem. Medical benefit PA submissions for commercial and Medicare Advantage plans primarily route through Availity Essentials, supporting both direct portal interaction and X12 278 transactions via clearinghouses. Pharmacy PAs, managed by CarelonRx, leverage CoverMyMeds and Surescripts ePA. Furthermore, specialty benefit management for domains like advanced imaging and cardiology is handled by Carelon Medical Benefits Management, requiring separate portal submissions. Klivira’s integration with Epic Orchestrate streamlines this by intelligently directing requests to the correct Anthem channel, reducing manual channel selection and potential errors.

Integrating Anthem Policy Access and Clinical Criteria

Effective prior authorization requires precise adherence to payer medical policies and clinical guidelines. Anthem operating companies publish comprehensive policy libraries through provider sites accessed via Availity, with state-specific variations. For services under Carelon Medical Benefits Management, clinical guidelines are published directly on the Carelon MBM provider site. Klivira, within an Epic Orchestrate workflow, can help surface relevant policy information, including whether criteria are Anthem-developed, Carelon-developed, MCG-based, or NCCN-compendium-based, ensuring that submissions are clinically aligned from the outset.

Leveraging Electronic PA and Da Vinci Initiatives for Anthem Submissions

Elevance Health, through its Anthem operating companies, has participated in Da Vinci Project initiatives and HL7 connectathons, indicating a commitment to electronic prior authorization (ePA) standards like Da Vinci PAS. While specific production conformance requires verification of current public disclosures, Klivira is designed to leverage these emerging FHIR-based capabilities. Separately, Carelon Medical Benefits Management operates its own electronic submission pathway for its in-scope domains, distinct from Anthem's general Da Vinci posture. For retail pharmacy, CoverMyMeds and Surescripts ePA are key partners for CarelonRx.

Addressing Turnaround Times and Common Denial Patterns

Anthem-licensed plans' PA turnaround times are governed by state insurance regulations for commercial lines, with material variance across states. Medicare Advantage, Medicaid managed-care, and QHP-on-FFM lines are subject to CMS-0057-F, mandating 72-hour standard and 24-hour expedited decision timeframes. Common Anthem denial categories include medical necessity, step therapy non-completion, site-of-service mismatch, and non-formulary pharmacy denials. Klivira’s integration with Epic Orchestrate helps proactively address these by guiding users through documentation requirements and flagging potential issues before submission, thereby improving first-pass authorization rates and compliance with payer SLAs.

Key Considerations for Anthem PA Automation via Epic Orchestrate

**Channel Orchestration:** Ensure Epic Orchestrate workflows accurately route PA requests to Availity, CarelonRx ePA partners, or Carelon MBM portals based on benefit type and service category.
**Policy Integration:** Develop processes to access and apply the correct Anthem medical policies or Carelon MBM clinical guidelines, referencing specific policy numbers and effective dates.
**X12 278 Optimization:** Maximize automated X12 278 transactions for eligible medical PAs, leveraging Epic Orchestrate to prepare and transmit necessary data elements.
**Denial Prevention:** Configure Orchestrate to prompt for specific clinical documentation and address common Anthem denial reasons, such as site-of-service or step therapy requirements.
**Compliance Monitoring:** Monitor state-specific turnaround time regulations and CMS-0057-F requirements for Medicare Advantage and Medicaid lines, integrating these into workflow metrics.

Frequently asked questions

How does Epic Orchestrate help with Anthem's varied PA submission channels?

Epic Orchestrate, when integrated with Klivira, can intelligently direct prior authorization requests to the appropriate Anthem submission channel. This includes Availity Essentials for many medical PAs, CarelonRx's ePA partners (CoverMyMeds, Surescripts) for pharmacy benefits, or the dedicated Carelon Medical Benefits Management portal for specific specialty services like advanced imaging, reducing manual decision-making and ensuring correct routing.

Can Epic Orchestrate access Anthem's medical policies and clinical guidelines?

While Epic Orchestrate itself is a workflow engine, Klivira can be configured to surface or link to Anthem's medical policies and clinical guidelines. These are typically published on Anthem's provider sites accessed via Availity, or on the Carelon Medical Benefits Management provider site for services under their purview. This integration helps ensure that submissions align with the most current medical necessity criteria.

What role do X12 278 transactions play in Anthem PA automation with Epic Orchestrate?

Anthem-licensed plans accept X12 278 transactions for many medical-benefit prior authorizations. Epic Orchestrate can be configured to prepare and transmit the necessary data for these electronic submissions through integrated clearinghouses. Klivira enhances this by streamlining the data extraction from the EMR and formatting it for compliant X12 278 transmission, optimizing the automation of these requests.

How does CMS-0057-F impact Anthem PA workflows within Epic Orchestrate?

CMS-0057-F directly impacts Anthem's Medicare Advantage and Medicaid managed-care plans, mandating specific decision timeframes (72-hour standard, 24-hour expedited). Epic Orchestrate workflows, supported by Klivira, can be designed to prioritize these requests, track submission times, and facilitate timely follow-up to ensure compliance with these federal regulations and avoid potential penalties.

Are behavioral health services for Anthem also managed through Epic Orchestrate?

Behavioral health services for many Anthem lines are managed through Carelon Behavioral Health. The specific routing and PA requirements (carve-out vs. in-network) vary by line of business and state. Epic Orchestrate, integrated with Klivira, can be configured to handle these specific behavioral health PA workflows, directing requests to the appropriate Carelon Behavioral Health channels where applicable.