Authorizations for post-acute care services for Commercial members

For services beginning on July 1, 2023, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) for members of most Commercial plans¹ will be reviewed by Carelon Post Acute Solutions, LLC (formerly MyNexus, Inc.).² Through this program, Carelon Post Acute Solutions, LLC clinicians will collaborate with caregivers and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services.

The goal of this program is to support members through their recovery process in the most appropriate environment.

With this program implementation please note the following changes:

• Anthem Blue Cross and Blue Shield will transition to Carelon Post Acute Solutions, LLC Clinical Appropriateness Guidelines. The guideline can be accessed here.
• The modified prior authorization requirements for admissions to in-network SNF providers (effective March 1, 2021), that allow a five-day initial length of stay upon notification of an admission to an in-network SNF facility will no longer apply; and
• The modified prior authorization requirements for admissions to in-network LTACH providers (effective April 18, 2022), that allow a seven-day initial length of stay upon notification of an admission to an in-network LTACH will no longer apply.

Members included in the PAC Review Program

Local Commercial fully insured and ASO members.

Members of the following products are excluded: National Accounts, HealthLink, California HMO, New York HMO, State of New York, City of New York, Blue Card Host, Federal Employee Program® (FEP®). 

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon Post Acute Solutions, LLC will begin receiving requests on Wednesday, June 28, 2023, for members whose anticipated discharge date is July 1, 2023, or after.

Providers are encouraged to request authorization using NexLync. Go to the Carelon Post Acute Solutions, LLC website to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the Carelon Post Acute Solutions, LLC Provider Call Center at 833-431-0780 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to Carelon Post Acute Solutions, LLC at 833-702-0788.

To learn more about Carelon and upcoming training webinars, visit https://providers.carelonmedicalbenefitsmanagement.com/postacute or email PACprovider_relations@carelon.com.

If you have additional questions, please call the Carelon Post Acute Solutions, LLC Provider Call Center at 833-431-0780.

1 An up-to-date list of in-scope plans will be maintained on the Carelon Post-Acute Solutions LLC web site.

2 Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to July 1, 2023, should be directed to the health plan.