Transition to Carelon Medical Benefits Management, Inc. site of care guidelines

Effective December 30,2023, Empire BlueCross BlueShield (Empire) will transition the Clinical Criteria for site of care reviews to the following Carelon Medical Benefits Management* site of care guidelines to perform medical necessity and clinical appropriateness reviews for the requested site of care for certain procedures.

 Note: These reviews do not apply to procedures performed on an emergent basis.

Carelon Medical Benefits Management also manages the musculoskeletal level of care review using The Carelon Musculoskeletal Appropriate Use Criteria: Level of Care for Musculoskeletal Surgery and Procedures guideline. 

Members included in the program

The new review criteria apply to all Empire members currently participating in the above mentioned Carelon Medical Benefits Management programs. To determine if prior authorization (PA) by Carelon Medical Benefits Management is required for a 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), Medicare, Medicare supplement and the Federal Employee Program® (FEP).

Prior authorization requirements

PA requirements remain the same. For services scheduled to begin on or after December 29, 2023, care providers must contact Carelon Medical Benefits Management to obtain PA. Requested services received on or after December 29, 2023, will be reviewed with the new Clinical Criteria.

Care providers may submit PA requests to Carelon Medical Benefits Management at providerportal.com. Initiating a request and entering all the requested clinical information will provide an immediate determination 24/7.

For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may download a copy of the current and upcoming guidelines here.