Optimizing Anthem (Elevance Health) Prior Authorizations with Klivira's Automation Platform

For healthcare organizations seeking to streamline prior authorization workflows, navigating the complexities of Anthem (Elevance Health) notable health requirements demands a robust automation strategy.

Revenue cycle leaders and prior authorization teams face significant operational burdens managing diverse payer requirements. Klivira offers a specialized solution to automate and accelerate prior authorizations with Anthem (Elevance Health), addressing common pain points from submission to appeal and enhancing efficiency across your organization.

The Challenge of Anthem (Elevance Health) Prior Authorization

Managing prior authorizations for Anthem-licensed plans involves a multi-faceted approach due to their varied submission channels and policy structures. From commercial to Medicare Advantage lines, understanding the specific intake points and clinical criteria for each service is critical for timely approvals and reducing administrative overhead.

Navigating Anthem's Diverse Submission Channels

Anthem (Elevance Health) utilizes several distinct pathways for prior authorization submissions. Medical benefit PAs for commercial and Medicare Advantage plans typically route through Availity Essentials, supporting both direct portal entry and X12 278 transactions via clearinghouses. Pharmacy benefit PAs, managed by CarelonRx, leverage ePA partners like CoverMyMeds and Surescripts.

Key Anthem (Elevance Health) Prior Authorization Channels

Availity Essentials for medical benefit PA, inpatient admissions, and concurrent review.
X12 278 electronic transactions for medical benefit services.
CarelonRx provider PA system, CoverMyMeds, and Surescripts for pharmacy benefit PA.
Carelon Medical Benefits Management (formerly AIM Specialty Health) portal for advanced imaging, cardiology, MSK, sleep, and radiation oncology.
Carelon Behavioral Health for specific behavioral health services, depending on the plan.

Streamlining Policy Access and Clinical Criteria

Accessing the correct utilization management policies for Anthem (Elevance Health) is crucial for accurate submissions. Anthem operating companies publish medical policies and clinical guidelines via provider sites accessed through Availity. For services managed by Carelon Medical Benefits Management, specific clinical guidelines are found on the Carelon MBM provider site, often referencing criteria from MCG or NCCN for oncology.

Klivira's Approach to Anthem (Elevance Health) PA Automation

Klivira's platform automates the complex prior authorization process for Anthem (Elevance Health), integrating directly with their diverse submission channels and policy libraries. By leveraging intelligent automation, Klivira helps organizations navigate the specific requirements of Anthem, CarelonRx, and Carelon Medical Benefits Management, ensuring submissions align with payer criteria.

Integrating with Your EMR for Seamless Workflows

Klivira integrates directly with your existing EMR system, creating a unified workflow for Anthem (Elevance Health) prior authorizations. This integration minimizes manual data entry, reduces errors, and ensures that all necessary clinical documentation is automatically attached, accelerating the PA process from initiation to decision.

Addressing Common Anthem Denial Patterns

Klivira's automation platform is designed to anticipate and mitigate common Anthem (Elevance Health) denial reasons, such as medical necessity, site-of-service mismatch, and step therapy requirements. By ensuring submissions are complete and compliant with specific payer policies, Klivira helps reduce initial denials and streamlines the appeals process, which can vary between standard Anthem and Carelon MBM-managed services.

Frequently asked questions

How does Klivira handle Anthem's multiple PA submission channels?

Klivira's platform is engineered to connect with Anthem's various submission channels, including Availity Essentials, X12 278 transactions, and ePA partners like CoverMyMeds and Surescripts for pharmacy benefits. We also support integration with Carelon Medical Benefits Management's portal for specialty services.

Can Klivira help with Anthem (Elevance Health) specific policy lookup?

Yes, Klivira's system is configured to assist in referencing the appropriate Anthem medical policies and clinical guidelines, which are published through provider sites accessed via Availity. For services under Carelon Medical Benefits Management, our platform helps direct users to the relevant Carelon MBM clinical guidelines.

How does Klivira ensure compliance with Anthem's turnaround times, including CMS-0057-F?

Klivira's automation helps accelerate the submission process, contributing to faster decisions. For Anthem's Medicare Advantage and Medicaid plans, our system helps track submissions in alignment with CMS-0057-F requirements for 72-hour standard and 24-hour expedited decisions.

What kind of EMR integrations does Klivira offer for Anthem (Elevance Health) prior authorizations?

Klivira offers robust EMR integrations, often leveraging SMART on FHIR capabilities, to automatically extract required patient and clinical data for Anthem (Elevance Health) prior authorizations. This minimizes manual effort and ensures that all necessary documentation is prepared for submission.

Does Klivira support the appeal process for Anthem (Elevance Health) denials?

Klivira's platform facilitates the appeals process by organizing denial reasons and supporting documentation. We help streamline the submission of appeals, whether through the standard Anthem operating-company process or the separate Carelon Medical Benefits Management pathway, including peer-to-peer review requests.