New Carelon Medical Benefits Management, Inc. programs effective December 1, 2024

At Anthem, we are always looking for ways to create value for our stakeholders. With that in mind, we are pleased to announce that effective December 1, 2024, Anthem will transition the review of radiology, cardiovascular, musculoskeletal, sleep, and genetic testing requests for Anthem members to Carelon Medical Benefits Management, Inc. 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.

This relationship with Carelon Medical Benefits Management enables Anthem to ensure that care aligns with established evidence-based medicine. Carelon Medical Benefits Management will follow the clinical hierarchy established by Anthem for medical necessity determination. When existing guidance does not provide sufficient clinical detail, Carelon Medical Benefits Management will determine medical necessity using an objective, evidence-based process.

Pre-service review requirements

Beginning November 18, 2024, care providers will be able to contact Carelon Medical Benefits Management for prior authorization (PA) of services that take place on or after December 1, 2024. Care providers are strongly encouraged to verify that a PA has been obtained before scheduling and performing any service.

Contact Carelon Medical Benefits Management to obtain pre-service authorization for the following non-emergency services:

Radiology services:

• CT/CTA
• MR (MRI, MRA, MRM, MRS, fMRI)
• Nuclear cardiology
• PET scans

Cardiovascular services:

• Diagnostic coronary angiography with or without right or left heart catheterization
• Percutaneous coronary intervention (PCI), such as coronary stents and balloon angioplasty
• Arterial duplex
• Physiologic study arterial
• Stress echocardiography (SE)
• Resting echocardiography (TTE)
• Transesophageal echocardiography (TEE)

Sleep testing and therapy:

• Home and facility-based sleep testing, including:

• Polysomnography (PSG)
• Home sleep testing (HST)
• Multiple sleep latency testing (MSLT)
• Maintenance of wakefulness testing (MWT)
• Titration studies

• Initial and ongoing treatment orders, including:

• Automatic positive airway pressure (APAP) therapy
• Continuous positive airway pressure (CPAP) therapy
• Bi-level, or variable positive airway pressure (BPAP) therapy
• Oral appliance therapy

Musculoskeletal procedures

Spine surgery — cervical, thoracic, lumbar, and sacral:

• Bone grafts
• Bone growth stimulators
• Cervical/lumbar spinal fusions
• Cervical/lumbar spinal laminectomy
• Cervical/lumbar spinal discectomy
• Cervical/lumbar spinal disc arthroplasty (replacement)
• Sacroiliac joint fusion
• Spinal deformity (scoliosis/kyphosis)
• Vertebroplasty/kyphoplasty

Joint surgery:

• Hip arthroplasty
• Knee arthroplasty
• Shoulder arthroplasty
• Hip arthroscopy
• Knee arthroscopy
• Shoulder arthroscopy
• Treatment of osteochondral defects
• Meniscal allograft transplantation

Interventional pain management:

• Epidural injections (interlaminar/caudal and transforaminal)
• Facet joint injections/medial branch blocks
• Facet joint radiofrequency nerve ablation
• Implanted spinal cord stimulators
• Regional sympathetic blocks
• Sacroiliac joint injections

Genetic testing:

• Reproductive carrier screening
• Prenatal testing
• Rare disease testing
• Whole exome/genome sequencing
• Hereditary cancer testing
• Tumor markers
• Hereditary cardiac testing
• Neurogenetic and neuromuscular testing
• Pharmacogenomics and thrombophilia testing
• Susceptibility testing for common diseases

For a list of in-scope procedure codes, please see the attached list. Please note that the codes included in the program are subject to change; verify pre-authorization requirements by using the Carelon Medical Benefits Management provider portal.

Members included in the new program

Included membership:

• Medicaid

Excluded membership:

• Commercial
• Medicare
• FEP

How to submit a request for review

Beginning November 18, 2024, providers can begin submitting requests for review or verify order numbers using one of the following methods:

• Online:

• The Carelon Medical Benefits Management provider portal is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to providerportal.com.
• Providers can also access the Carelon Medical Benefits Management provider portal through Availity.

• By phone:

• Call Carelon Medical Benefits Management toll-free at (833)-500-6966, Monday through Friday between 7 a.m. and 7 p.m. CT and 8 a.m. to 8 p.m. ET.

Upcoming webinars

Before the Carelon Medical Benefits Management call center and provider portal going live on November 18, 2024, there will be helpful webinars and Q&A sessions for care providers and office staff to learn more about each program and how to use the provider portal. We strongly encourage you and your practice to participate even if you are already familiar with Carelon Medical Benefits Management and the provider portal through other health plans or specialty programs.

Live webinar sessions with Q&A will cover topics such as:

• How the program and preauthorization request process work.
• Which members and services will require preauthorization.
• Demonstration of the Carelon Medical Benefits Management provider portal and how to enter order requests.
• Sharing additional resources.
• Q&A with our Solution Operations leaders.

Please register to attend at least one training opportunity. Your facility’s attendance is highly encouraged. Carelon Medical Benefits Management solution-specific training content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training.

In the weeks leading up to the program's go-live, a recording of each solution training will be made available on the Carelon Medical Benefits Management provider portal for all registered provider portal users.

For more information

To learn more about Carelon Medical Benefits Management, please visit Carelon.com or contact Provider Services.