Updates to Carelon Post-Acute Care Clinical Appropriateness Guidelines

Effective for dates of service on and after September 1, 2024, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management, Inc. guideline annual review process, these updates focus on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates

All post-acute care (PAC) guidelines — skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term acute care hospital (LTACH):

• Re-structured original guidelines into three separate, level of care-specific guidelines
• Updated background and definitions and refined several criteria to be more applicable to each guideline after re-structuring
• Removed most criteria pertaining to transfer between other levels of PAC
• Removed facility accessibility and health-related social needs (HRSN) criteria
• Removed requirement for physician referral
• Added sub-criteria to existing criteria in ongoing care regarding remaining therapeutic goals
• Added verbiage and examples for clarification of original intent or for more level of care-specific applicability

LTACH only:

• Refined criteria around need for hospice/palliative care consultation

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon Medical Benefits Management will begin receiving requests on May 29, 2024, for members whose anticipated discharge date is June 1, 2024, or after.

Providers are encouraged to request authorization using NexLync. Go to the Carelon Medical Benefits Management 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.

To learn more about Carelon Medical Benefits Management and upcoming training webinars, visit https://providers.carelonmedicalbenefitsmanagement.com/postacute or email PACprovider_relations@carelon.com.

If you are unable to access/use any of the links or have other questions, call the Carelon Medical Benefits Management Provider Call Center at 833-431-0780 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday.