Reminder - Updated Carelon Musculoskeletal Program effective April 1, 2023: monitored anesthesia care reviews
Unless otherwise stated in the provider’s agreement, for services on or after April 1, 2023, prior authorization will be required for the clinical appropriateness of monitored anesthesia or conscious sedation (MAC) when requested in conjunction with interventional pain codes. Carelon will use the following Anthem Clinical UM Guideline: CG-MED-78: Anesthesia Services for Interventional Pain Management Procedures. The Clinical Criteria to be used for these reviews can be found on the Anthem provider website Clinical UM Guidelines page. Clinical site of care review may also apply if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center. If you have a member in a current course of treatment for pain management where services were approved without reviewing the MAC, identify the member for us at the next request. Please note, this does not apply to procedures performed on an emergent basis.
The anesthesiologist may determine that a member requires monitored anesthesia on the day of service. A retrospective review may be requested, or a post service claim may be submitted with a clinical record including the pre-anesthesia assessment, the patient’s medical history documenting that patient meets criteria for MAC, and a detailed description of the procedure performed for Carelon to determine coverage for the service as medically necessary.
At this time, the codes that will be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940. A complete list of CPT® codes requiring prior authorization for the Carelon Monitored Anesthesia Care for Interventional Pain program is available on the Carelon Musculoskeletal microsite. To determine if prior authorization is needed for a member on or after April 1, 2023, 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 the Availity Essentials* platform to pre-certify an outpatient musculoskeletal service will receive a message referring the provider to Carelon. (Note: ICR cannot accept prior authorization requests for services administered by Carelon.)
Members included in the new program
All fully insured members currently participating in the Carelon Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the Carelon Musculoskeletal Program to add to their members’ benefit package as of April 1, 2023.
Members of the following products are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP®).
Pre-service review requirements
For services provided on or after April 1, 2023, ordering and servicing providers may begin contacting Carelon as early as March 20, 2023, for review. Providers may submit prior authorization requests to Carelon in one of the following ways:
- Access Carelon’s ProviderPortalSM directly at www.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 Carelon’s ProviderPortalSM and entering responses to all the requested clinical questions will allow you to receive an immediate determination.
- Access Carelon via Availity Essentials* at www.availity.com in Payer Spaces under the Resources tab.
- Call the Carelon Contact Center’s toll-free number at 877-291-0360, Monday through Friday, 8 a.m. to 5 p.m. ET.
Carelon will be offering two Monitored Anesthesia Care training sessions that providers are invited to attend:
- Thursday March 30, 2023 – 12 p.m. ET
- Thursday April 6, 2023 – 12 p.m. ET
We value your participation in our network and look forward to working with you to help improve the health of our members.
March 2023 Anthem Provider News - Virginia