Carelon Medical Benefits Management, Inc. expanded Musculoskeletal Review Program — important program update

In the September 2023 edition of the Provider News, we announced the expansion of the Carelon Medical Benefits Management Musculoskeletal (MSK) Program. We want to inform you that there has been a change in the program implementation timeline. As previously announced, the medical necessity/clinical appropriateness reviews for the requested site of service for certain spine, joint, and interventional pain procedures will be implemented on December 29, 2023.

However, the implementation date for reviews for monitored anesthesia or conscious sedation (MAC), when requested in conjunction with interventional pain codes has been delayed. A new program date has not yet been determined. An update will be provided at least 30 days prior to the start of this program.

As a reminder, the 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 Appropriateness Guidelines when performing these reviews. The Clinical Criteria to be used can be found by accessing the links below.

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.

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 training webinars

We invite you to take advantage of a free informational webinar that will introduce the program and the robust capabilities of the Carelon Medical Benefits Management ProviderPortal. Use the links below 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.