Authorizations for post-acute care services for Commercial members

For services beginning on October 1, 2023, 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 plans¹ will be reviewed by Carelon Post Acute Solutions, LLC* (formerly myNEXUS).² Through the Post-Acute Care (PAC) Review Program, Carelon Post Acute Solutions clinicians will collaborate with caregivers and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate environment.

With this program implementation, Anthem Blue Cross and Blue Shield will transition to Carelon Post Acute Care Clinical Appropriateness Guidelines. The guideline can be accessed here.

Members included in the PAC Review Program:

• Local Commercial fully insured and ASO members

Members of the following products are excluded: National Accounts, HealthLink, California HMO, New York HMO, State of New York, City of New York, JAA, BlueCard Host, and Federal Employee Program^® (FEP^®).

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon Post Acute Solutions will begin receiving requests on September 28, 2023, for members whose anticipated discharge date is October 1, 2023, or after.

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 are unable to use the link or website, you can call the Carelon Post Acute Solutions 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 the Carelon Post Acute Solutions Provider Resources page or email PACprovider_relations@carelon.com.

If you have additional questions, call the Carelon Post Acute Solutions Provider Call Center at 833-431-0780.

¹ An up-to-date list of in-scope plans will be maintained on the Carelon Post Acute Solutions website.
² Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to October 1, 2023, should be directed to the health plan.