Change to New England Health Plan prior authorization requirements for certain Carelon Medical Benefits Management, Inc. programs

New prior authorization requirements are being implemented for New England Health Plan (NEHP) Large Group clients. 

Effective for dates of service on or after January 1, 2024, prior authorization will be required for radiology, sleep, and cardiology procedures administered by Carelon Medical Benefits Management, Inc.* 

Prior authorizations requests for services rendered prior to January 1, 2024, will adhere to the previous guideline for prior authorization requests. 

Members included in the new prior authorization requirements: All fully insured NEHP Large Group members are included. Below are NEHP groups and prefixes affected by this change:

Members excluded from the new prior authorization requirements: Some self-funded (ASO) NEHP Large Group members may be excluded from this new prior authorization requirement. 

To determine if prior authorization is needed for services provided on or after January 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information.

Obtaining prior authorization

For services provided on or after January 1, 2024, ordering and servicing providers may begin contacting Carelon Medical Benefits Management as early as December 1, 2023, for review. Submit prior authorization requests to Carelon Medical Benefits Management in one of the following ways:

• Access Carelon Medical Benefits Management’s ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. Initiating a request on Carelon Medical Benefits Management’s ProviderPortal_SM and entering responses to all the requested clinical questions will allow you to receive an immediate determination.
• Access Carelon via Availity Essentials* at Availity.com in Payer Spaces under the Resources tab.
• Call the Carelon Contact Center’s toll-free number at 877-291-0360, Monday through Friday, 
   8 a.m. to 5 p.m. ET.

We value your participation in our network and look forward to working with you to help improve the health of our members.