Carelon Medical Benefits Management provides prior authorization and post service medical necessity review for certain outpatient services for some members of the following plans:
- Blue Preferred PPO
- Blue Focus POS
- Blue Choice
- Blue Choice HSA
- Blue Options
- Blue Options HSA
Carelon reviews the following services:
- Genetic testing
- Oncology
- Radiation therapy
- Radiology
- Musculoskeletal spine surgery
Before Submitting Requests to Carelon
Verify eligibility and benefits and check prior authorization requirements through Availity Essentials® or your preferred vendor before rendering services. This will help determine if a prior authorization is needed for the member and if it’s required through Carelon. Authorization requirements can vary depending on the member’s benefits.
Ordering physicians or servicing providers (facilities) may submit prior authorization requests.
Payment may be denied if procedures are performed without authorization. If denied, you may not bill the patient.
Ensure you have all the following before requesting a prior authorization from Carelon:
- Patient’s identification number, name and date of birth
- Ordering physician's or professional provider's name, address and telephone
- Imaging provider information (name, location)
- Imaging exams being requested (body part, right, left or bilateral)
- Patient diagnosis (suspected or confirmed)
- Clinical symptoms
- Additional information may be necessary for complex cases including results of past treatment history (previous tests, duration of previous therapy, relevant clinical medical history)
Submission Requests to Carelon
Use the Carelon provider portal to request reviews for the fastest turnaround time.
Do not submit medical records unless requested by Carelon.
Attend free training sessions on how to submit requests for Carelon Prior Authorizations. Refer to the Carelon On-demand training page for available sessions.
If you cannot use the provider portal, you may call Carelon at 844-377-1285.
For technical support, call 800-859-5299.
Physicians or professional providers may fax clinical information for existing requests to 800-610-0050.
After Submitting Requests to Carelon
Based on clinical criteria, Carelon will issue a prior authorization order number or forward the case to a nurse or physician for review.
The physician reviewer may contact the ordering provider to discuss the case in greater detail within two business days of receipt of the request. Ordering physicians or professional providers may also contact Carelon's physician reviewer at any time during the review process.
If criteria are not met or additional information is needed, the case will be automatically transferred for further clinical evaluation.
When criteria are met, Carelon will provide an approved request order number, which will include the dates it is valid. This is not a guarantee of payment. The claim will be processed in accordance with the terms of a member's health benefit plan.