Policy Updates Prior AuthorizationCommercialJuly 1, 2024

Program implementation announcement: Authorizations for post-acute care services by Carelon Medical Benefits Management, Inc.

On December 1, 2023, we announced a delay in the implementation of the prior authorization program for Post-Acute Care (PAC) services administered by Carelon Medical Benefits Management, Inc., formerly Carelon Post Acute Solutions, LLC. It was further announced that a notification would be published at least 30 days prior to implementation of the program. The confirmed new program implementation date is August 1, 2024.

For services beginning on August 1, 2024, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) for members of most commercial plans will be reviewed by Carelon Medical Benefits Management. The goal of this program is to support members through their recovery process in the most appropriate environment. 

With this program implementation, Anthem will transition to Carelon Medical Benefits Management Clinical Appropriateness Guidelines. The guidelines can be accessed here.

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon Post Acute Solutions will begin receiving requests on July 29, 2024, for members whose anticipated discharge date is on or after August 1, 2024. 

Providers are encouraged to request authorization using NexLync. Go to the Carelon Post Acute Solutions website to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. 

If you have questions or are unable to use the above link or website, call the Carelon Provider Call Center at 833-431-0780 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday.

To learn more about Carelon Post Acute Solutions and upcoming training webinars, visit providers.carelonmedicalbenefitsmanagement.com/postacute or email PACprovider_relations@carelon.com.

Through our efforts, we can help our care provider partners deliver high quality, equitable healthcare.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: July 2024 Provider Newsletter