Automating Anthem (Elevance Health) Specialty Drug Prior Auth Workflows

Anthem's Specialty Drug Prior Auth Landscape

Anthem-licensed plans, part of Elevance Health, manage specialty drug prior authorizations across both medical and pharmacy benefits. Submissions for medical-benefit specialty drugs typically route through Availity Essentials, utilizing X12 278 transactions or the portal interface. Pharmacy-benefit specialty drugs are managed by CarelonRx, Anthem's in-house PBM, leveraging ePA partners like CoverMyMeds and Surescripts.

Key Considerations for Anthem Specialty Drug PA

• **Benefit-Side Determination:** Accurately identifying whether a specialty drug falls under the medical or pharmacy benefit is crucial, as this dictates the submission pathway and associated policies.
• **Site-of-Care Policies:** Anthem frequently enforces site-of-care policies for medical-benefit specialty injectables and infusions, often steering away from hospital outpatient settings.
• **Multi-Channel Submission:** Providers must navigate Availity for medical benefit, CarelonRx's systems for pharmacy benefit, and dedicated ePA platforms for retail pharmacy submissions.
• **Policy Access:** Medical policies and clinical guidelines are published on Anthem provider sites via Availity, with state-specific variations and disclosures regarding criteria sources (e.g., Anthem-developed, MCG, NCCN).
• **Carelon MBM Distinction:** Be aware that Carelon Medical Benefits Management handles distinct domains like advanced imaging or MSK, which operate on separate submission and policy platforms from general medical or specialty drug PA.

Klivira's Approach to Anthem Specialty Drug PA Automation

Klivira's platform provides a comprehensive solution for automating Anthem (Elevance Health) specialty drug prior authorization. Our system intelligently determines the correct benefit side (medical or pharmacy) for each drug and patient, ensuring submissions are routed to the appropriate channel from the outset. This eliminates a common failure point and accelerates time-to-therapy.

Intelligent Routing and Documentation for Anthem Submissions

For pharmacy-benefit specialty drugs, Klivira integrates with ePA partners like CoverMyMeds and Surescripts, utilizing NCPDP SCRIPT ePA for efficient retail pharmacy submissions. For medical-benefit specialty drugs, we leverage X12 278 transactions and direct portal integrations, populating required clinical data—including step-therapy history from FHIR MedicationRequest and Observation resources—to meet Anthem's specific documentation requirements. Our logic also incorporates Anthem's site-of-care policies, flagging potential mismatches before submission.

Navigating Turnaround Times and Denial Patterns

Anthem's PA turnaround times are governed by state regulations for commercial plans and by CMS-0057-F for Medicare Advantage and Medicaid lines, which mandates 72-hour standard and 24-hour expedited decisions. Klivira's proactive approach helps minimize delays by ensuring complete, accurate submissions. Common Anthem denial reasons, such as medical necessity, uncompleted step therapy, or site-of-service mismatches, are addressed through automated documentation and policy alignment, reducing rework and appeals.

Enhancing Post-Approval Workflows

Beyond submission, Klivira coordinates the post-approval specialty-pharmacy fulfillment workflow for pharmacy-benefit drugs, facilitating a smoother transition to patient medication delivery. While Klivira identifies manufacturer copay assistance program availability, our platform focuses on optimizing the PA process itself, providing clarity on potential Medicare patient exclusions for these programs.