Streamlining Aetna OptumRx Integration for Prior Authorization Workflows

Managing prior authorizations for both Aetna and OptumRx presents distinct challenges. Klivira's platform facilitates seamless Aetna OptumRx integration, centralizing diverse submission channels and policy requirements.

Revenue cycle directors and prior authorization coordinators face increasing complexity in navigating varied payer and PBM requirements. This page outlines the specific considerations for Aetna's medical and pharmacy benefit prior authorizations, alongside the distinct processes required for OptumRx pharmacy benefit management, and how Klivira streamlines these critical workflows.

Navigating Aetna's Prior Authorization Ecosystem

Aetna, a CVS Health company, manages prior authorizations across medical and pharmacy benefits through distinct channels. Medical benefit requests typically route via the Availity provider portal or X12 278 transactions. Pharmacy benefit PAs for Aetna members are administered by CVS Caremark, often submitted through ePA partners like CoverMyMeds or Surescripts.

Understanding OptumRx Prior Authorization Requirements

For patients whose pharmacy benefits are managed by OptumRx, a separate set of prior authorization requirements applies. As a prominent PBM, OptumRx handles specialty and standard pharmacy benefit prior authorizations. Providers must adhere to OptumRx's specific formulary, clinical criteria, and submission pathways, which are independent of Aetna's internal PBM processes.

Klivira's Approach to Aetna OptumRx Integration

Klivira automates prior authorization submissions and tracking across both Aetna and OptumRx. Our platform connects to Aetna's primary submission channels, including Availity and X12 278, and integrates with ePA partners used by CVS Caremark for Aetna's pharmacy benefits. Simultaneously, Klivira supports the specific workflows required for OptumRx prior authorizations, providing a unified solution for diverse PBM and payer interactions.

Aetna Policy Adherence and Documentation

Aetna's medical necessity criteria are detailed in its Clinical Policy Bulletins (CPBs), publicly available and structured by topic. For pharmacy benefits under CVS Caremark, specific drug lists and step therapy protocols apply. Klivira's integration helps ensure that documentation submitted for Aetna PAs aligns with the relevant CPB numbers and clinical criteria, reducing common denial reasons related to insufficient information.

Optimizing Turnaround Times and Electronic Submissions

Adhering to state-mandated and payer-published turnaround times is crucial for Aetna and OptumRx. Aetna's medical PA decisions are impacted by state regulations and CMS-0057-F for Medicare Advantage. Klivira's platform facilitates electronic submissions, leveraging X12 278 and ePA channels like CoverMyMeds and Surescripts, to accelerate the prior authorization process and improve compliance with decision timeframes for both Aetna and OptumRx.

Frequently asked questions

How does Klivira handle Aetna's medical vs. pharmacy benefit PAs?

Klivira integrates with Aetna's medical PA channels like Availity and X12 278 for medical benefits. For Aetna's pharmacy benefits, administered by CVS Caremark, Klivira supports submissions through ePA partners such as CoverMyMeds and Surescripts, ensuring comprehensive coverage across both benefit types.

Is OptumRx Aetna's PBM?

No, OptumRx is not Aetna's PBM. Aetna's pharmacy benefits are administered by CVS Caremark. OptumRx is a separate PBM, primarily for UnitedHealthcare members, and has its own distinct prior authorization processes and requirements.

What documentation does Aetna typically require for medical PAs?

Aetna medical prior authorizations typically require documentation aligning with their Clinical Policy Bulletins (CPBs). This often includes clinical notes, imaging reports, lab results, and evidence of failed conservative therapies, all directly supporting the medical necessity criteria outlined in the specific CPB.

How does Klivira improve turnaround times for Aetna and OptumRx PAs?

Klivira enhances turnaround times by enabling electronic submission via X12 278 for Aetna medical PAs and through ePA partners for pharmacy PAs. This reduces manual effort, minimizes data entry errors, and ensures requests are sent through the most efficient digital channels available, aligning with payer-specific SLAs and regulatory mandates like CMS-0057-F.

Can Klivira help with Aetna's step therapy requirements?

Yes, Klivira assists with Aetna's step therapy requirements by facilitating the submission of documentation proving adherence to or exceptions from these protocols. Aetna publishes step-therapy protocols within applicable Clinical Policy Bulletins (CPBs), and Klivira helps ensure that submitted requests include the necessary information to address these criteria.