Authorizations for post-acute care services for Commercial members

For services beginning on December 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 [Carelon LLC]).² Through this program, Carelon LLC 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, Empire BlueCross BlueShield will transition to Carelon LLC 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, 32BJ, New York Hotel Trades, JAA, Blue Card Host, Federal Employee Program® (FEP®).  

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon LLC will begin receiving requests on Tuesday, November 28, 2023, for members whose anticipated discharge date is December 1, 2023, or after. 

Providers are encouraged to request authorization using NexLync. Go to the Carelon LLC 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 LLC 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 PAS and upcoming training webinars, visit PAC-IM Program - Carelon Post Acute Solutions (carelonmedicalbenefitsmanagement.com) or email PACproviderrelations@carelon.com.

If you have additional questions, please call the Carelon LLC Provider Call Center at 833-431-0780.