CommercialMay 31, 2023
Effective August 1, 2023, Carelon Medical Benefits Management, Inc. programs will expand
As communicated in the April Provider Newsletter, effective August 1, 2023, Carelon Medical Benefits Management, Inc.* (formerly AIM Specialty Health® [AIM]) will expand multiple Carelon programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross and Blue Shield (Anthem) members.
The expansion will require clinical appropriateness review for additional procedures related to the Carelon cardiology, genetic testing, and radiology programs. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon will begin accepting prior authorization requests on July 17, 2023, for dates of service August 1,2023, and after.
Members included in the new program
All fully insured, self-funded (ASO), and national members currently participating in the Carelon programs listed below are included. For ASO groups that currently do not participate in the Carelon programs, the program will be offered to ASO accounts to add to their members’ benefit package as of August 1, 2023.
Members of the following products are excluded:
- Medicare Advantage
- Medicaid
- Medicare
- Medicare supplement
- Medicare Advantage Group Retiree Solutions
- Federal Employee Program® (FEP)
Pre-service review requirements
For procedures that are scheduled to begin on or after August 1, 2023, all providers must contact Carelon to obtain pre-service review for the following non-emergency modalities. Please refer to the clinical guidelines on the microsite resource pages for complete code lists.
Program | Services | Clinical guidelines |
Cardiology |
|
|
Genetic testing |
|
|
Radiology |
|
|
To determine if prior authorization is needed for a member on or after August 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the interactive care reviewer (ICR) tool on the Availity Essentials* website to pre‑certify an outpatient procedure will receive a message referring the provider to Carelon.
Note: ICR cannot accept prior authorization requests for services administered by Carelon.
Providers should continue to submit pre-service review requests to Carelon using the convenient online service via the Carelon ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com to register.
Provider training webinars
For Carelon facilitates quarterly training and Q&A, go to https://bit.ly/40Vddwn to register for an upcoming session. If you have previously registered for other services managed by AIM, there is no need to register again.
For more information
Go to https://providers.carelonmedicalbenefitsmanagement.com/genetictesting, https://providers.carelonmedicalbenefitsmanagement.com/cardiology/, or https://providers.carelonmedicalbenefitsmanagement.com/radiology/ for resources to help your practice get started with the radiology, cardiology, and genetic testing programs. Our special websites will allow you to access information and tools, such as order entry checklists, clinical guidelines, and FAQs.
If you have any questions, call your local Provider Relationship Management representative, or call the Provider Services number on the back of the member’s ID card.
We value your participation in our network and look forward to working with you to help improve the health of our members.
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Availity, LLC is an independent company providing administrative support services on behalf of the health plan.
MULTI-BCBS-CM-024774-23-CPN24718
PUBLICATIONS: June 2023 Provider Newsletter
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