Carelon, formerly known as AIM Specialty Health, is a specialty health benefits company that works with leading insurers to improve health care quality and manage costs for today’s most complex and prevalent clinical guidelines, tests and treatments, helping to promote care that is appropriate, safe and affordable. Carelon provides prior authorization and post service medical necessity review for certain outpatient services (excluding Medicare Advantage and Healthy Montana Kids plans.)
Be sure to verify eligibility and benefits and check prior authorization requirements through or your preferred vendor to determine if a prior authorization is needed for the patient depending on their benefit plan.
Carelon Prior Authorization Program
Carelon provides required prior authorization review for select 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
With Carelon administering prior authorizations, we can optimize our programs, further ensuring that care aligns with established evidence-based medicine.
Outpatient Services Impacted
For services noted below select the category on thewebsite.
- Genetic Testing
- Radiation Therapy
- Radiology (applicable to some plans)
Prior Authorization Reminders
- Providers need to determine if prior authorization is required through Carelon before rendering services. Services can vary depending on the patient benefits.
- Ordering physicians or servicing providers (facilities) may submit prior authorization requests.
- Payment may be denied if procedures are performed without authorization and health care providers may not bill the patient.
Benefits of the Carelon ProviderPortal for Pre & Post-Service Reviews:
- Offers self-service, smart clinical algorithms and in many instances, real-time determinations
- Check prior authorization status
- Increases payment certainty
- Provides faster pre-service decision turnaround times than post service reviews
- Medical records for pre or post-service reviews are not necessary unless specifically requested by Carelon.
Submitting Requests to Carelon
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)
Providers are encouraged to utilize the Carelon ProviderPortal for the most efficient method to submit requests.
- Online: Log in to the Available 24/7/365
- For prior authorizations, Call 1-844-377-1285
- For technical support, Call 1-800-859-5299
- Fax: 1-800-610-0050
Note: Fax option is available only for physicians or professional providers who are submitting clinical information for existing requests.
- Do not submit medical records unless requested by 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 2 business days of receipt of the request.
- Ordering physician 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/participant's health benefit plan.
Carelon Medical Benefits Management is an independent company that has contracted with BCBSMT to provide utilization management services for members with coverage through BCBSMT.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT.
BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity or Carelon Medical Benefits Management.
Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.