Carelon Medical Benefits Management Expanded Musculoskeletal Review Program — effective December 29, 2023

Effective December 29, 2023, Carelon Medical Benefits Management, Inc.,*  a separate company, will expand the Musculoskeletal Program to perform medical necessity/clinical appropriateness reviews for:

1. The requested site of service for certain spine, joint, and interventional pain procedures.
2. Monitored anesthesia or conscious sedation (MAC), when requested in conjunction with interventional pain codes.

This Musculoskeletal Program applies to fully insured members of Empire BlueCross BlueShield (Empire) as outlined below.

Please note, these reviews do not apply to procedures performed on an emergent basis.

Carelon Medical Benefits Management will use the following Clinical Guidelines when performing these reviews. The Clinical Criteria to be used can be found by accessing the links below: Clinical Appropriateness Guidelines Surgical Appropriate Use Criteria: Site of Service CG-MED-78: Anesthesia Services for Interventional Pain Management Procedures.

Site of care reviews

Carelon Medical Benefits Management will continue to manage the Musculoskeletal Program and level of care review. The Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the level of care review.

A subset of the Carelon Medical Benefits Management Musculoskeletal Program codes will be reviewed for site of care. A complete list of CPT^® codes requiring prior authorization for the Musculoskeletal Site of Care program is available on the Carelon Medical Benefits Management Musculoskeletal microsite.

MAC reviews

The codes that will be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940. A complete list of CPT^® codes requiring prior authorization for the Monitored Anesthesia Care for Interventional Pain program is available on the Carelon Medical Benefits Management Musculoskeletal microsite. If you have a member in a current course of treatment for pain management where services were approved without reviewing the MAC, identify the member for us at the next request.

Site of care review may also apply if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center.

The anesthesiologist may determine that a member requires monitored anesthesia on the day of service. A retrospective review may be requested, or a post service claim may be submitted with a clinical record including the pre-anesthesia assessment, the patient’s medical history documenting that patient meets criteria for MAC, and a detailed description of the procedure performed for Carelon Medical Benefits Management to determine coverage for the service as medically necessary.    

Members included in the program

All fully insured members currently participating in the Carelon Medical Benefits Management Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the Musculoskeletal Program to add to their members’ benefit package as of December 29, 2023. To determine if prior authorization for the Carelon Medical Benefits Management Musculoskeletal Program applies to an Empire member, contact the Provider Services phone number on the back of the member’s ID card.

The following members are excluded: Medicare Advantage (individual and group), Medicaid, Medicare, Medicare supplement, and the Federal Employee Program^® (FEP^®).

Prior authorization requirements

For services scheduled to begin on or after December 29, 2023, care providers must contact Carelon Medical Benefits Management to obtain prior authorization. Ordering and servicing care providers may begin contacting Carelon Medical Benefits Management on December 18, 2023.

Care providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access ProviderPortal directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. Initiating a request on ProviderPortal and entering all the requested clinical questions will allow you to receive an immediate determination.
• Access Carelon Medical Benefits Management via the Availity Essentials* platform at Availity.com.
• Call the Carelon Medical Benefits Management Contact Center toll-free number at 866-714-1107, Monday through Friday, 8 a.m. to 5 p.m.
• The Musculoskeletal Program microsite helps you learn more and access helpful information and tools such as order entry checklists.

Note: If a care provider office attempts to use the Interactive Care Reviewer (ICR) tool on the Availity Essentials platform to prior authorize an outpatient musculoskeletal case, ICR will produce a message referring the care provider to Carelon Medical Benefits Management (ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management).

Musculoskeletal Site of Care and MAC training webinars

We invite you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the Carelon Medical Benefits Management ProviderPortal. Go to the Musculoskeletal Program microsite to register for an upcoming webinar. If you have previously registered for other services managed by Carelon Medical Benefits Management, there is no need to register again.

We value your participation in our network and look forward to working with you to improve the health of our members.