Policy Updates Prior AuthorizationCommercialMay 2, 2025

SHBP Precertification Procedure Codes Sheet

This article was updated on July 21, 2025.

Carelon Medical Benefits Management, Inc.: Carelon Medical Benefits Management, a separate company, is a nationally recognized leader in specialty benefits management. To submit your request for any of the services below, contact Carelon Medical Benefits Management on line via their ProviderPortal, providerportal.com. From the drop-down menu, select Anthem - SHBP UM. You may also call Carelon Medical Benefits Management toll-free at 866-714-1103, Monday to Friday, 8 a.m. to 6 p.m. ET.

Diagnostic Imaging Management: Diagnostic imaging management services are provided by Carelon Medical Benefits Management for certain health plan members. Diagnostic imaging services may be reviewed against Carelon Medical Benefits Management's Diagnostic Imaging Utilization Management Clinical Guidelines. Carelon Medical Benefits Management's Clinical Guidelines are available at https://guidelines.carelonmedicalbenefitsmanagement.com. lf you have any questions about which guidelines apply, call the customer service number on the back of the member's ID card.

Radiation therapy services: Review of Anthem - SHBP UM outpatient radiation therapy services are also done by Carelon Medical Benefits Management. Care providers must contact Carelon Medical Benefits Management for prior authorization for the following nonemergency outpatient: intensity modulated radiation therapy (IMRT), proton beam radiation therapy, stereotactic radiosurgery (SRS)/stereotactic body radiotherapy (SBRT), and brachytherapy. Radiation therapy performed as part of an inpatient admission will continue to be reviewed through Anthem - SHBP UM's inpatient precertification process. Prior authorization is required through Carelon Medical Benefits Management for all Anthem - SHBP UM members, with the exception of members with Anthem - SHBP UM as secondary coverage.

Outpatient sleep testing and therapy services: The specialty benefit management program for outpatient sleep testing and therapy services for obstructive sleep apnea is administered by Carelon Medical Benefits Management and includes the following: home sleep test (HST); in-lab sleep study (PSG); titration study; initial treatment order (APAP, CPAP, BPAP, oral devices, appliances and related supplies); and ongoing treatment order (APAP, CPAP, BPAP, oral devices, appliances, and related supplies). Anthem - SHBP UM uses sleep diagnostic and treatment guidelines developed by Carelon Medical Benefits Management. Carelon Medical Benefits Management's Obstructive Sleep Apnea Diagnostic and Treatment Management Guidelines are available at https://guidelines.carelonmedicalbenefitsmanagement.com/current-sleep-guidelines. The precertification requirement applies to Anthem - SHBP UM members. The requirement does not apply to those for whom Anthem - SHBP UM is secondary coverage, including those whose primary insurance carrier is Medicare.

Specialty medications: Specialty medications will be reviewed by Carelon Rx, Inc, a seprate company. Prior authorization requirement does not indicate coverage. Check benefits to see if the specialty medication is covered under Anthem - SHBP UM Medical or CVS Caremark pharmacy vendor. For questions regarding the specialty meds requiring precert, call 855-668-6442

Learn more: SHBP Precertification Procedure Codes Sheet (PDF)

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan.

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

GABCBS-CM-082586-25, GABCBS-CM-088763-25

ATTACHMENTS: SHBP Precertification Procedure Codes Sheet (pdf - 23.2mb)