Anthem (Elevance Health) Prior Authorization Automation

Navigating Anthem's Diverse Prior Authorization Channels

Anthem-licensed plans utilize a complex ecosystem of submission channels depending on the benefit category. Klivira's platform intelligently routes requests through the correct pathway, eliminating manual channel selection errors and ensuring timely submission. This includes primary medical PA, specialty benefit management, and pharmacy requests.

Key Anthem Submission Channels Supported by Klivira:

• **Medical PA (Commercial & Medicare Advantage):** Submissions via Availity Essentials and X12 278 transactions for medical benefit services.
• **Pharmacy PA:** Routing through CarelonRx's provider system, including ePA integrations with CoverMyMeds and Surescripts for prescriber-initiated workflows.
• **Specialty Services:** Direct electronic submission to Carelon Medical Benefits Management (formerly AIM Specialty Health) for advanced imaging, cardiology, MSK, sleep, and radiation oncology.
• **Behavioral Health:** Handling for services managed by Carelon Behavioral Health, verifying carve-out arrangements per line of business.
• **Specialty Drugs (Medical Benefit):** Adherence to Anthem's site-of-care and clinical-indication policies, with routing based on therapeutic category.

Automated Policy Lookup and Documentation for Anthem Cases

Understanding and adhering to Anthem's medical policies and clinical utilization management guidelines is critical for approvals. Klivira's engine ingests and applies these criteria, automating documentation assembly and ensuring requests are complete per payer requirements, whether Anthem-developed, Carelon-developed, MCG-based, or NCCN-compendium-based.

Klivira's End-to-End Automation for Anthem Prior Authorizations

Our platform provides comprehensive automation across the prior authorization lifecycle, tailored to Anthem's operational specifics. From order entry to final disposition, Klivira minimizes manual touchpoints, accelerates decision times, and reduces denial rates for Anthem-licensed plans.

Key Automation Steps for Anthem Workflows:

• **EMR-Integrated Detection:** Utilizing CDS Hook events to identify Anthem PA requirements at the point of order entry.
• **Automated Documentation Assembly:** Pulling relevant FHIR resources from the EMR to build comprehensive packets according to Anthem's specific policy criteria.
• **Payer-Aware Channel Routing:** Submitting requests via the optimal channel for Anthem, including X12 278, Availity's portal, Carelon MBM's portal, or ePA partners.
• **Real-Time Status Tracking:** Monitoring Anthem's decision status via X12 277/835 transactions and portal updates, with status write-back to the EMR.
• **Automated Denial Routing & Appeals:** Parsing Anthem denial reasons (e.g., X12 CARC/RARC codes) and facilitating automated or human-assisted appeal preparation, including for common issues like site-of-service mismatch.

Compliance and Turnaround Times for Anthem Plans

Anthem's PA turnaround times are governed by state-specific regulations for commercial plans and federal mandates like CMS-0057-F for Medicare Advantage, Medicaid managed care, CHIP, and QHP-on-FFM. Klivira tracks these critical deadlines, helping your organization meet compliance requirements and expedite patient access to care, particularly for the 72-hour standard and 24-hour expedited decision timeframes.

Addressing Anthem-Specific Denial Patterns

Common denial categories for Anthem include medical necessity, insufficient documentation, step therapy non-compliance, and notably, site-of-service mismatches due to Carelon's active policies. Klivira's system is designed to proactively address these issues by ensuring complete documentation and correct channel routing, reducing preventable denials and streamlining the appeal process.