Expansion of Carelon Medical Benefits Management, Inc. programs

Effective October 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works 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 additional procedures related to Carelon Medical Benefits Management programs, including cardiology, radiation oncology, radiology, musculoskeletal, sleep, surgical, and additional outpatient services.

Carelon Medical Benefits Management will follow the clinical hierarchy established by Anthem for medical necessity determination. Anthem makes coverage determinations based on CMS guidance, including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, Carelon Medical Benefits Management will determine medical necessity using an objective, evidence-based process.

Carelon Medical Benefits Management will continue to use criteria documented in the Medical Policies and Clinical Guidelines of Anthem listed in the table below. These Clinical Guidelines can be found at Availity.com.

Detailed prior authorization (PA) requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at Availity.com. Contracted and noncontracted care providers should call Provider Services at the phone number on the back of the member’s ID card for PA requirements.

Prior authorization review requirements

Carelon Medical Benefits Management will begin accepting PA requests on September 24, 2024, for dates of service October 1, 2024, and after. For procedures scheduled to begin on or after
October 1, 2024, care providers must contact Carelon Medical Benefits Management to obtain PA for the non‑emergency modalities below. Refer to the clinical guidelines on the microsite resource pages for complete code lists.

To determine if PA is needed for a member on or after October 1, 2024, call Provider Services using the phone number on the back of the member’s ID card. Care providers using the interactive care reviewer (ICR) tool on Availity.com for PA requests on an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management (Note: ICR cannot accept PA requests for services administered by Carelon Medical Benefits Management).

How to place a review request

Care providers may place a PA request online to Carelon Medical Benefits Management by way of providerportal.com. ProviderPortal_SM is available 24/7, processing requests in real-time using clinical criteria.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, surgical, and programs, visit:

• Cardiovascular Solution | Carelon Insights
• Musculoskeletal (MSK) Solution | Carelon Insights (AIM)
• Sleep Solution | Sleep Healthcare | Carelon Insights
• Surgical Procedures Solution | Carelon Insights
• Radiation Oncology Solution | Carelon Insights

Our website helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQ.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.