Reminder: Updated Carelon Medical Benefits Management, Inc. Musculoskeletal Program effective April 1, 2023 - Site of care reviews

We previously communicated that Carelon Medical Benefits Management, Inc.,* a separate company, would expand the Musculoskeletal Program to perform medical necessity review of the requested site of service for certain joint and interventional pain procedures beginning September 1, 2022. The expansion was delayed and will now be effective April 1, 2023, for Anthem Blue Cross and Blue Shield (Anthem) fully insured consumers, as further outlined below.

Carelon Medical Benefits Management, Inc. will continue to manage the Musculoskeletal Program and level of care review. The Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the level of care review. Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care). Carelon Medical Benefits Management, Inc. will use the following Anthem clinical utilization management guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The clinical criteria to be used for these reviews can be found on the Anthem Provider website Clinical UM Guidelines page. Note, this does not apply to procedures performed on an emergent basis.

A subset of the Musculoskeletal Program codes will be reviewed for site of care. A complete list of CPT^® codes requiring prior authorization for the Musculoskeletal Site of Care Program is available on the musculoskeletal microsite. To determine if prior authorization is needed for an Anthem consumer on or after April 1, 2023, contact the Provider Services phone number on the back of the consumer’s ID card for benefit information. If providers use the interactive care reviewer (ICR) tool on the Availity Essentials* website to pre-certify an outpatient musculoskeletal procedure, ICR will produce a message referring the provider to Carelon Medical Benefits Management, Inc.

Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management, Inc.

Consumers included in the new program

This program will be available to fully insured members that currently participate in the Carelon Medical Benefits Management, Inc. Musculoskeletal Program that have added the Musculoskeletal Site of Care Program to their consumers’ benefit package as of April 1, 2023.

Consumers of the following products are excluded from this program:

• 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 Medical Benefits Management, Inc. as early as March 15, 2023, for review. Providers may submit prior authorization requests to Carelon Medical Benefits Management, Inc. in one of several ways:

• Access the ProviderPortal_SM directly at 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.
• Access Carelon Medical Benefits Management, Inc. via the Availity Essentials website at availity.com.
• Call the Carelon Medical Benefits Management, Inc. Contact Center toll-free number at 877‑430-2288, Monday through Friday, 8 a.m. to 6 p.m. Eastern time.

Training webinars

Carelon Medical Benefits Management, Inc. will be offering two Musculoskeletal Site of Care Program training sessions that providers are invited to attend:

• Thursday, March 9, 2023 – 11 a.m. CT
• Wednesday, March 15, 2023 – 11 a.m. CT

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