Policy Updates Medical Policy & Clinical GuidelinesCommercialJuly 18, 2023

Expansion of Carelon Medical Benefits Management, Inc. cardiology programs effective October 1, 2023

As communicated in the July Provider Newsletter, effective October 1, 2023, Carelon Medical Benefits Management, Inc.* a specialty health benefits company, will perform medical necessity reviews for procedures for Anthem Blue Cross and Blue Shield (Anthem) members, as outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable. 

The expansion will require clinical appropriateness review for pacemakers as part of the Carelon Medical Benefits Management Cardiology program. Due to CPT® code overlap, management of ICD and CRT devices without inclusion of pacemakers creates provider abrasion and operational challenges. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 18, 2023, for dates of service October 1, 2023, and after. 

Members included in the new program

All fully insured, self-funded (ASO), and National members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of August 1, 2023.

Members of the following products are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, and Federal Employee Program® (FEP®).

Pre-service review requirements

For procedures that are scheduled to begin on or after October 1, 2023, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following non-emergency modalities. 

Please refer to the clinical guidelines at the links below for more details including code lists.

Leadless pacemakers: Medical policy related to the insertion, removal, or replacement of permanent leadless pacemakers.

Carelon Medical Benefits Management permanent implantable pacemakers: Clinical appropriateness guideline related to insertion, repair, removal, repositioning, or replacement of permanent implantable pacemakers, pacemaker pulse generators, or electrodes. 

To determine if prior authorization is needed for a member on or after October 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials* website to pre-certify an outpatient procedure, will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com to register. 

For more information

Go to providers.carelonmedicalbenefitsmanagement.com/cardiology for resources to help your practice get started with the Cardiology program. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs.

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

* Carelon Medical Benefits Management, Inc. is an independent company providing administrative support services on behalf of the health plan. Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

MULTI-BCBS-CM-028688-23- CPN28575

PUBLICATIONS: August 2023 Provider Newsletter