Automating Anthem (Elevance Health) Peer-to-Peer Scheduling Workflows

Klivira's platform automates Anthem (Elevance Health) peer-to-peer scheduling, transforming a high-friction process into an efficient workflow that reduces administrative burden and accelerates clinical reviews.

For revenue cycle leaders and prior authorization teams, managing peer-to-peer (P2P) reviews with Anthem-licensed plans presents unique challenges due to diverse submission channels and policy libraries. Klivira addresses these complexities by integrating directly into your EMR and orchestrating the entire P2P scheduling process, from denial detection to outcome capture.

Navigating Anthem's Diverse P2P Pathways

Anthem (Elevance Health) operates through multiple channels for prior authorization and subsequent peer-to-peer reviews. Medical benefit PAs typically route through Availity Essentials, while specialty benefits like advanced imaging or cardiology are managed by Carelon Medical Benefits Management via its dedicated portal. Pharmacy PAs, handled by CarelonRx, often leverage ePA partners like CoverMyMeds and Surescripts. Klivira's automation intelligently identifies the correct P2P pathway based on the initial denial source, ensuring requests are directed appropriately.

Klivira's Automated P2P Scheduling for Anthem Denials

Our platform begins by auto-detecting P2P-eligible denials, which are often returned via X12 277/835 transactions or Availity status updates, indicating clinical necessity disagreements or insufficient documentation. Klivira then initiates the P2P request through the relevant Anthem contact mechanism, whether it's via portal, secure messaging, or direct outreach, capturing available medical director windows. This eliminates the manual coordination burden that often leads to missed P2P opportunities.

Streamlined Pre-Call Preparation and Documentation

**Intelligent Denial Triage:** Klivira's denial-router automatically identifies cases where a peer-to-peer review is the optimal next step, rather than an immediate formal appeal.
**Clinician Calendar Integration:** We integrate with your ordering clinicians' calendars (via FHIR Appointment resource or systems like Outlook/Google Calendar) to find mutually available time slots with Anthem's medical directors.
**Automated Packet Assembly:** Klivira pulls relevant clinical notes, prior-line therapy, lab/imaging results, and peer-reviewed literature via FHIR to create a structured pre-call packet, delivered to the clinician 24-48 hours before the call.
**Policy Alignment:** Documentation is curated to address specific Anthem medical policies accessed via Availity, or Carelon MBM clinical guidelines, depending on the service category.

Reducing Clinician Burden and Accelerating Outcomes

Manual peer-to-peer scheduling is a significant contributor to clinician burnout and delays in patient care, as highlighted by AMA surveys. Klivira's automation addresses critical failure modes: eliminating the three-way scheduling friction, preventing missed P2P windows through automated reminders, and ensuring clinicians are fully prepared with comprehensive documentation. Post-call, Klivira captures outcomes via a structured form and writes back to your EMR as FHIR DocumentReference and Communication resources, triggering downstream workflows like approval write-backs or appeal escalations.

Actionable Analytics for Continuous Improvement

Beyond individual case management, Klivira provides P2P pattern analytics. By analyzing success rates by denial reason, specific Anthem plan, and clinician, your team gains insights to refine upstream prior authorization submissions. This feedback loop helps identify common denial categories, such as 'site-of-service mismatch' or 'medical necessity' for Anthem, informing documentation improvements that can reduce the need for future P2P interventions.

Frequently asked questions

How does Klivira handle P2P scheduling for Anthem's different medical policy sources?

Klivira's platform is designed to identify the correct policy source based on the service denied. For standard medical PAs, documentation aligns with Anthem medical policies found via Availity. For specialty services under Carelon Medical Benefits Management (e.g., advanced imaging), our system references Carelon MBM's specific clinical guidelines, ensuring the clinician has the relevant criteria for their P2P review.

Can Klivira integrate with my EMR for clinician calendar access?

Yes, Klivira integrates with your EMR via FHIR Appointment resources where supported, or through direct integrations with common calendar systems like Microsoft Outlook and Google Calendar. This allows us to automatically identify and propose mutually available time slots between your clinicians and Anthem's medical directors, minimizing manual coordination.

What kind of documentation does Klivira assemble for Anthem P2P calls?

For Anthem P2P calls, Klivira automatically compiles a comprehensive pre-call packet. This includes relevant clinical notes, prior-line therapy history, lab and imaging results, and peer-reviewed literature for off-label indications. This documentation is tailored to address common Anthem denial reasons like 'medical necessity' or 'insufficient documentation' and is delivered to the clinician prior to the scheduled call.

How does Klivira track the outcome of an Anthem peer-to-peer review?

After an Anthem P2P call, Klivira provides a structured form for clinicians to capture the outcome (e.g., approval, modification, upheld denial). This information is then automatically routed back into your EMR as FHIR DocumentReference and Communication resources, ensuring consistent record-keeping and triggering any necessary follow-up actions, such as updating the authorization status or initiating an appeal.

Does Klivira's automation cover P2P for Anthem's pharmacy benefits?

Yes, Klivira's P2P automation extends to pharmacy benefit denials managed by CarelonRx. Our system identifies pharmacy-related denials, including those processed via CoverMyMeds or Surescripts ePA, and facilitates the scheduling and documentation preparation for peer-to-peer reviews with CarelonRx's medical directors, similar to medical benefit PAs.