Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024

As communicated in the November 2023, provider newsletter, 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 Therapy programs.

Carelon Medical Benefits Management will follow the clinical hierarchy established by Anthem for medical necessity determination. For Medicare Advantage, Anthem makes coverage determinations based on guidance from CMS including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, Carelon Medical Benefits Management will determine medical necessity using an objective, evidence-based process.

Carelon Medical Benefits Management will continue to use criteria documented in Anthem Medical Policies and Clinical Guidelines listed in the table below. These clinical guidelines can be reviewed online at Availity.com.

Detailed prior authorization requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at Availity.com. Contracted and noncontracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.

Prior authorization review requirements

Carelon Medical Benefits Management will begin accepting prior authorization requests on March 18, 2024, for dates of service April 1, 2024, and after. For procedures that are scheduled to begin on or after April 1, 2024, all providers must contact Carelon Medical Benefits Management to obtain prior authorization for the following non-emergency modalities. Refer to the clinical guidelines on the microsite resource pages for complete code lists.

Note: The procedure list has been updated since the November notification.

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 for prior authorization requests on 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.

How to place a review request

Providers may place a prior authorization request online to Carelon Medical Benefits Management using the convenient online service via the ProviderPortal_SM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using clinical criteria.

Go to https://www.providerportal.com/ to register.

For more information

For resources to help your practice get started with the Radiology, Cardiology, Genetic Testing, Musculoskeletal, Surgical, and Radiation Oncology programs, go to:

• https://providers.carelonmedicalbenefitsmanagement.com/genetictesting
• https://providers.carelonmedicalbenefitsmanagement.com/cardiology/
• https://providers.carelonmedicalbenefitsmanagement.com/radiology/
• https://providers.carelonmedicalbenefitsmanagement.com/musculoskeletal/

Our special websites will help you learn more and will allow you to access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs.

For additional help, you can also call your local provider relationship management representative.

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