CommercialJuly 24, 2024
Expansion of Carelon Medical Benefits Management, Inc. programs
As a reminder, effective October 1, 2024, Carelon Medical Benefits Management 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 continued migration will expand clinical appropriateness review for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, radiation oncology, radiology, sleep, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — additional outpatient utilization management (UM) that will include some transportation (including ambulance) and fertility procedures as set forth below. Transportation may include emergency post-service reviews.
The Clinical UM Guidelines and Medical Policies (also known as coverage guidelines in Virginia) by Anthem for medical necessity review are listed in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 23, 2024, for dates of service on or after October 1, 2024.
Members included in the new program
Updates to Carelon Medical Benefits Management programs apply to select local fully insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplemental, or Federal Employee Program® (FEP®). For more information, please contact the phone number on the back of the member ID card.
Pre-service review requirements
For procedures that are scheduled to begin on or after October 1, 2024, all care providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including, but not limited to, the following non-emergency modalities. Please refer to the Clinical Guidelines at anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.
Note: All codes will be reviewed for medical necessity for the requested service and not for site of care. Please note some services below are effective March 1, 2025.
Program | Services | Medical Policies or Clinical Guidelines |
Cardiovascular |
|
|
Musculoskeletal |
|
|
Radiology |
|
|
Radiation oncology |
|
|
Sleep |
|
|
Surgical GI |
|
|
Update to previous notice: The services additional outpatient utilization management and base surgical below are effective March 1, 2025.
Program | Services | Medical Policies or Clinical Guidelines | |
Additional outpatient utilization management services (effective 3/1/2025) |
|
| |
Cardiovascular services effective 3/1/2025 |
|
| |
Base surgical effective 3/1/2025 |
|
| |
To determine if prior authorization is needed for a member on or after October 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on Availity.com 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.)
Care 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 provider portal. The provider portal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providerportal.com to register.
For more information
For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:
- Cardiovascular Solution | Carelon Insights
- Radiology Solution | Carelon Insights
- Sleep Solution | Sleep Healthcare | Carelon Insights
- Surgical Procedures Solution | Carelon Insights
- Radiation Oncology Solution | Carelon Insights
- Additional Outpatient Utilization Management
Our website at anthem.com helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQ. You can also contact your local network relations representative if you have any questions.
Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.
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.
MULTI-BCBS-CM-063152-24-CPN62856
PUBLICATIONS: August 2024 Provider Newsletter
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