Expansion of Carelon Medical Benefits Management, Inc. cardiology, genetic testing, and radiology programs effective August 1, 2023

Effective August 1, 2023, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross and Blue Shield (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 cardiology, genetic testing, and radiology 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 July 17, 2023, for dates of service August 1, 2023, and after.

Members included in the new program

All fully insured (FI), self-funded (ASO) 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 August 1, 2023.

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

Pre-service review requirements

For procedures that are scheduled to begin on or after August 1, 2023, all care providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following nonemergency modalities. Please refer to the program microsite resource pages for complete code lists.

To determine if prior authorization is needed for a member on or after August 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. (Note: Providers cannot use the Interactive Care Reviewer (ICR) tool on Availity Essentials* to pre-certify an outpatient procedure or any 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 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to Carelon Medical Benefits Management to register.

For more information

Visit the resources below to help your practice get started with the radiology, cardiology, and genetic testing programs.

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

You can also reach out to your local Network Relations representative.

Resources:

• Carelon Medical Benefits Management, Inc. genetic testing program
• Carelon Medical Benefits Management, Inc. cardiology program
• Carelon Medical Benefits Management, Inc. radiology program