Expansion of Carelon Medical Benefits Management, Inc. programs

Effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem members as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical and Radiation Oncology 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 Medical Benefits Management will begin accepting prior authorization requests on March 18, 2024, for dates of service April 1, 2024, and after.

Members included in the new program

All FI, self -funded (ASO), HealthLink, and national members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of April 1, 2024. A separate notice will be published for Medicare Advantage, Medicare, and MA GRS.

Members of the following products are excluded: Medicaid, Medicare supplement, Federal Employee Program® (FEP®).

Pre-service review requirements

For procedures that are scheduled to begin on or after April 1, 2024, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including but not limited to the following non-emergency modalities. Please refer to the clinical guidelines on the microsite resource pages for complete code lists.

Please note: The procedure list has been updated since the November notification. All codes will only be reviewed for medical necessity for the requested service and not for site of care at this time. Vascular procedures will not require prior authorization for National members currently participating in the Carelon Medical Benefits Management Cardiology program.

To determine if prior authorization is needed for a member on or after April 1, 2024, 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 Availity Essentials to pre-certify an outpatient procedure, will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortal_SM. ProviderPortal is available twenty-four hours a day, seven days a week, processing requests in real-time using clinical criteria. Go to providers.carelonmedicalbenefitsmanagement.com/ to register.

For more information

Go to https://providers.carelonmedicalbenefitsmanagement.com/genetictesting, https://providers.carelonmedicalbenefitsmanagement.com/cardiology/, https://providers.carelonmedicalbenefitsmanagement.com/radiology/, https://providers.carelonmedicalbenefitsmanagement.com/musculoskeletal/, https://providers.carelonmedicalbenefitsmanagement.com/surgicalprocedures/; for resources to help your practice get started with the Radiology, Expanded Cardiology, Genetic Testing, Musculoskeletal, Surgical, and Radiation Oncology programs. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs, or you can call your local Network Relations representative.

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