Anthem (Elevance Health) eviCore Integration: Klivira's Strategy for Specialty PA

Klivira streamlines prior authorization for specialty services, addressing the complexities often associated with Anthem (Elevance Health) eviCore integration.

Revenue cycle leaders and prior authorization coordinators face significant challenges when managing specialty service PAs, especially with large payers like Anthem. Understanding the precise submission channels and clinical criteria is critical for efficient processing and avoiding denials. Klivira simplifies this intricate landscape.

Understanding eviCore's Role in Specialty Benefit Management

eviCore Healthcare (now Evernorth eviCore) is a prominent specialty benefit management vendor, widely known for managing prior authorizations across various categories, including radiology, cardiology, oncology, and musculoskeletal services for numerous health plans. Their programs aim to ensure appropriate utilization of high-cost services, impacting workflows for providers nationwide.

Anthem (Elevance Health)'s Approach to Specialty PA: Carelon MBM

For Anthem-licensed plans, advanced imaging, cardiology, musculoskeletal (MSK), sleep, and radiation oncology services are managed by Carelon Medical Benefits Management (formerly AIM Specialty Health), an Elevance Health company. This distinct pathway routes these specific domains through Carelon MBM's dedicated provider portal, separate from Anthem's general medical PA channel via Availity Essentials.

Klivira's Integration with Anthem's Specialty Benefit Manager

Automated submission via Carelon MBM's provider portal for in-scope specialty services.
Intelligent extraction and attachment of required clinical documentation from EMRs.
Real-time status tracking and updates directly from Carelon MBM's system.
Seamless data flow and integration with existing EMRs for a unified workflow.
Facilitated access to Carelon MBM clinical guidelines for criteria adherence.

Navigating Anthem's Diverse PA Submission Channels

Anthem (Elevance Health) utilizes multiple channels for prior authorization submissions. General medical PAs for commercial and Medicare Advantage plans are typically routed through Availity Essentials, supporting X12 278 transactions. Pharmacy PAs are managed by CarelonRx, accepting submissions via their provider system or ePA partners like CoverMyMeds and Surescripts. Specialty services, as noted, are handled by Carelon MBM.

Key Considerations for Anthem Specialty PA Submissions

Verify if the specific service category routes through Carelon Medical Benefits Management.
Access clinical guidelines directly from the Carelon MBM provider site, not general Anthem policy libraries.
Be aware of potential site-of-care and clinical-indication policies, especially for specialty injectables.
Understand state-specific PA turnaround timeframes, as these vary materially for commercial plans.
Note that Carelon MBM denials for in-scope procedures follow a separate, Carelon-managed appeal pathway.

Klivira: Your Partner for Anthem (Elevance Health) PA Automation

Klivira provides a comprehensive automation platform designed to navigate the complex prior authorization landscape of Anthem (Elevance Health). By integrating with their diverse submission channels, including Carelon Medical Benefits Management, Klivira ensures efficient, accurate, and compliant PA processing, reducing administrative burden and accelerating patient care.

Frequently asked questions

How does Klivira handle eviCore integration for Anthem (Elevance Health) specialty services?

For Anthem (Elevance Health), advanced imaging and other specialty services typically managed by entities like eviCore for other payers are instead managed by Carelon Medical Benefits Management. Klivira integrates directly with Carelon MBM's provider portal and electronic submission pathways to automate these prior authorizations, ensuring accurate routing and efficient processing.

Where should advanced imaging prior authorizations for Anthem be submitted?

Advanced imaging, cardiology, MSK, sleep, and radiation oncology prior authorizations for Anthem-licensed plans are routed through the Carelon Medical Benefits Management provider portal. This is distinct from general medical PAs submitted via Availity Essentials.

How can I access clinical guidelines for Anthem specialty services managed by Carelon MBM?

Clinical guidelines for procedures routed through Carelon Medical Benefits Management are published on the Carelon MBM provider site. These are separate from the general Anthem medical-policy libraries, which are accessed via provider sites through Availity.

Does Anthem (Elevance Health) support X12 278 transactions for specialty PAs managed by Carelon MBM?

While Anthem-licensed plans accept X12 278 transactions via clearinghouses for general medical PAs, Carelon Medical Benefits Management operates its own dedicated electronic submission pathway for the specialty domains under its scope. Klivira integrates with these specific electronic channels for optimized submission.

What are common denial reasons for Anthem specialty services managed by Carelon MBM?

Common denial categories for Anthem specialty services managed by Carelon MBM include medical necessity, insufficient documentation, and site-of-service mismatch due to active Carelon site-of-care policies. Klivira's automation helps mitigate these by ensuring complete and accurate submissions.