Streamlining Anthem (Elevance Health) Imaging Prior Auth with Klivira

Klivira automates the complex process of Anthem (Elevance Health) imaging prior auth, ensuring accurate submissions to Carelon Medical Benefits Management and accelerating patient care pathways.

Navigating prior authorizations for advanced imaging with Anthem-licensed plans can be challenging, particularly given the specialized requirements of Carelon Medical Benefits Management. Klivira provides a robust solution designed to integrate seamlessly with your EMR, addressing the unique demands of this workflow for revenue cycle directors and prior authorization teams.

Navigating Anthem's Imaging Prior Authorization Landscape

For advanced imaging services like MRI, CT, and PET scans, Anthem-licensed plans primarily route prior authorization requests through Carelon Medical Benefits Management (formerly AIM Specialty Health). This distinct channel operates separately from general medical PA submissions via Availity Essentials, requiring specific portal engagement and adherence to Carelon MBM's clinical guidelines. Klivira ensures correct routing and data capture for these specialized submissions.

Key Challenges in Anthem Imaging PA Workflows

Accurate identification of the correct submission channel (Carelon MBM vs. Availity) for each member.
Adherence to Carelon MBM's specific clinical guidelines, often based on ACR Appropriateness Criteria.
High volume of peer-to-peer reviews for clinically complex cases.
Manual data entry into multiple portals, increasing administrative burden and potential for errors.
Delays in obtaining approvals, impacting patient scheduling and treatment timelines.

Klivira's Automated Approach to Anthem Imaging PA

Klivira integrates directly with your EMR via CDS Hooks, detecting advanced imaging orders at the point of care. Our platform automatically identifies the correct payer (Anthem) and the appropriate benefit manager (Carelon MBM), initiating the prior authorization process. This proactive detection and intelligent routing eliminate manual lookups and reduce the risk of missed authorizations.

Optimizing Submissions to Carelon Medical Benefits Management

Klivira streamlines submissions to the Carelon MBM provider portal by extracting necessary clinical documentation, ICD-10 diagnoses, and patient history directly from the EMR. Before submission, our system can evaluate the order against ACR Appropriateness Criteria, flagging potential issues and even suggesting alternative imaging options to the clinician, significantly reducing pre-service denials.

Leveraging Standards for Efficiency: X12 278 and Da Vinci PAS

While Anthem supports X12 278 transactions for medical PA, Carelon MBM operates its own electronic submission pathway for imaging. Klivira leverages these established channels and monitors developments in Elevance Health's participation in Da Vinci Project initiatives, including CRD and PAS, to ensure future-proof connectivity. Our platform optimizes data exchange regardless of the specific electronic standard.

Reducing Denials and Accelerating Patient Access

Common denial reasons for Anthem imaging requests include medical necessity, site-of-service mismatch, and insufficient documentation. Klivira's pre-submission appropriateness checks and comprehensive data capture minimize these risks. For clinical denials, our integrated workflow streamlines the peer-to-peer review process, ensuring timely engagement with Carelon MBM's medical directors and faster resolution.

Compliance and Turnaround Time Considerations

Anthem-licensed plans must adhere to state-specific commercial PA turnaround minimums, with Medicare Advantage and Medicaid lines also subject to CMS-0057-F requirements for 72-hour standard and 24-hour expedited decisions. Klivira's automation reduces internal processing times, helping your organization meet these critical deadlines and improve overall PA cycle times for Anthem imaging requests.

Frequently asked questions

How does Klivira handle imaging PA for Anthem plans that use Carelon Medical Benefits Management?

Klivira automatically identifies when an Anthem imaging order requires submission to Carelon Medical Benefits Management. Our platform then extracts all necessary clinical data from your EMR and populates the Carelon MBM provider portal, ensuring accurate and complete submissions without manual intervention.

What documentation does Anthem (Elevance Health) typically require for imaging prior auth?

For imaging prior auth routed through Carelon MBM, required documentation includes the clinical question, relevant ICD-10 diagnoses, prior imaging history, conservative care trials, and detailed symptom documentation. Klivira's system is configured to gather these specific data points from your EMR.

Can Klivira integrate with my EMR to automate Anthem imaging PA?

Yes, Klivira integrates with major EMR systems using SMART on FHIR and CDS Hooks. This integration enables real-time detection of imaging orders and automated data extraction, streamlining the entire Anthem imaging prior authorization workflow directly from your clinical system.

How does Klivira help reduce denials for Anthem imaging requests?

Klivira significantly reduces denials by performing pre-submission checks against ACR Appropriateness Criteria. This allows for identification of potential medical necessity gaps or alternative imaging recommendations before submission, minimizing rejections and subsequent peer-to-peer reviews.

Does Anthem support electronic PA for imaging via X12 278 or Da Vinci PAS?

Anthem supports X12 278 for general medical PA, and Carelon MBM has its own electronic submission pathway for imaging. While Elevance Health has participated in Da Vinci Project initiatives, specific production conformance requires verification. Klivira supports existing electronic channels and adapts to evolving standards.

What are the typical turnaround times for Anthem imaging prior authorizations?

Turnaround times for Anthem imaging PAs are governed by state-specific regulations for commercial plans and CMS-0057-F for Medicare Advantage and Medicaid (72-hour standard, 24-hour expedited). Klivira's automation helps your team meet these deadlines by accelerating the submission and internal processing phases.