Optimizing Anthem (Elevance Health) Prior Authorization in Maryland

Maryland's Prior Authorization Landscape with Anthem (Elevance Health)

Anthem, as an Elevance Health operating company, maintains a significant footprint in Maryland, encompassing commercial, Medicare Advantage, and Medicaid managed care plans. Prior authorization workflows for these lines of business are shaped by both Anthem's internal policies and state-specific mandates, requiring a nuanced approach to submission and compliance.

Anthem (Elevance Health) Prior Authorization Submission Channels

• **Medical PA (Commercial, Medicare Advantage):** Submissions route primarily through Availity Essentials, Anthem's multi-payer provider workspace. X12 278 transactions are also accepted via clearinghouses for impacted procedures.
• **Pharmacy PA:** Managed by CarelonRx (Elevance Health's in-house PBM), with submissions through CarelonRx's provider system, CoverMyMeds, and Surescripts ePA for prescriber-initiated workflows.
• **Specialty Benefits (e.g., Advanced Imaging, Cardiology, MSK):** These domains are managed by Carelon Medical Benefits Management (formerly AIM Specialty Health), requiring submission through their dedicated provider portal.
• **Behavioral Health PA:** For many Anthem lines, behavioral health services are managed through Carelon Behavioral Health (formerly Beacon Health Options); verify carve-out status per line of business and state.

Accessing Anthem (Elevance Health) Medical Policies and Clinical Guidelines

• **Anthem Medical Policies:** Published through provider sites accessed via Availity, with each state-licensed Anthem plan maintaining its own index, including state-specific Medicaid and MA variants.
• **Carelon MBM Clinical Guidelines:** For procedures routed through Carelon Medical Benefits Management (imaging, cardiology, MSK, sleep, radiation oncology), guidelines are published on the Carelon MBM provider site, separate from the main Anthem medical-policy library.
• **Criteria Vendor Disclosure:** Anthem medical policies typically disclose whether criteria are Anthem-developed, Carelon-developed, MCG-based, or NCCN-compendium-based for oncology.

Prior Authorization Turnaround Times and Regulatory Compliance in Maryland

• **State-Mandated Minimums:** Commercial PA timeframes for Anthem-licensed plans in Maryland are governed by state insurance regulations.
• **Payer-Published Service-Level Targets:** Anthem publishes precertification turnaround commitments through its provider portal, which should be verified regularly.
• **CMS-0057-F Applicability:** Anthem's Medicare Advantage, Medicaid managed care (under Anthem Medicaid plans and the Wellpoint subsidiary brand), CHIP, and QHP-on-FFM lines are impacted payers under CMS-0057-F, subject to its phased compliance timeline for 72-hour standard and 24-hour expedited PA decision timeframes.

Electronic Prior Authorization (ePA) Posture with Anthem (Elevance Health)

• **Da Vinci Project Initiatives:** Elevance Health, through its Anthem operating companies, has participated in Da Vinci Project initiatives and HL7 connectathons, indicating engagement with industry standards like PAS, CRD, and DTR.
• **Carelon MBM Electronic Submission:** Carelon Medical Benefits Management operates its own electronic submission pathway for its in-scope domains (imaging, cardiology, MSK, sleep, radiation oncology), distinct from Anthem's general Da Vinci posture.
• **Pharmacy ePA:** CoverMyMeds and Surescripts provide ePA capabilities for the retail pharmacy benefit through CarelonRx.

Understanding Anthem (Elevance Health) Denials and Appeals in Maryland

• **Common Denial Categories:** Anthem denials, returned via X12 277/835 transactions and Availity, frequently cite medical necessity, insufficient documentation, step therapy not completed, site-of-service mismatch (due to active Carelon policies), and procedure not covered under the specific state-plan benefit grid.
• **Appeal Pathways:** Standard medical PA denials follow the Anthem operating-company appeals process. Denials for procedures routed through Carelon Medical Benefits Management have a separate, Carelon-managed appeal pathway. Peer-to-peer reviews are available for both.

Klivira's Solution for Anthem (Elevance Health) PA in Maryland

Klivira integrates directly with EMRs and connects to key Anthem (Elevance Health) submission channels, including Availity and Carelon portals. Our platform automates the prior authorization process, from intelligent form completion and document submission to status tracking and denial management, helping Maryland providers navigate Anthem's complex requirements with greater efficiency and accuracy.