CommercialOctober 1, 2023
Transition to Carelon Medical Benefits Management, Inc. site of care guidelines
Effective December 30, 2023, Anthem Blue Cross and Blue Shield (Anthem) will transition the Clinical Criteria for site of care reviews to the following Carelon Medical Benefits Management* (Caralon) site of care guidelines to perform medical necessity and clinical appropriateness reviews for the requested site of care for certain procedures.
Program | Services | Carelon Guideline | CPT® code list links |
Surgical | Routine outpatient surgical procedures across the following specialty services: gastroenterology (including upper and lower endoscopy), ophthalmology (such as cataract surgery), gynecology, dermatology, urology, pulmonary and musculoskeletal | ||
Radiology | Routine outpatient CT and MRI imaging such as head, chest, and extremity imaging. | ||
Musculoskeletal | Select musculoskeletal and pain procedures, including shoulder and knee arthroscopies and epidural injections. | ||
Rehabilitative Services | Routine outpatient speech, occupational, and physical therapy services | Outpatient Rehabilitative and Habilitative Services Appropriate Use Criteria: Site of Care |
Note: These reviews do not apply to procedures performed on an emergent basis.
Carelon Medical Benefits Management also manages the musculoskeletal level of care review using The Carelon Musculoskeletal Appropriate Use Criteria: Level of Care for Musculoskeletal Surgery and Procedures guideline.
Members included in the program
The new review criteria apply to all Anthem members currently participating in the above mentioned Carelon Medical Benefits Management programs. To determine if prior authorization by Carelon Medical Benefits Management is required for a member, contact the Provider Services phone number on the back of the member’s ID card.
The following members are excluded: Medicare Advantage (individual and group),
Medicare, Medicare supplement, and the Federal Employee Program® (FEP).
Prior authorization requirements
Prior authorization requirements remain the same. For services scheduled to begin on or after December 29, 2023, care providers must contact Carelon Medical Benefits Management to obtain prior authorization. Requested services received on or after December 29, 2023, will be reviewed with the new Clinical Criteria.
Care providers may submit prior authorization requests to Carelon Medical Benefits Management at providerportal.com. Initiating a request and entering all the requested clinical information will provide an immediate determination 24/7.
For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may download a copy of the current and upcoming guidelines here.
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWI), Compcare Health Services Insurance Corporation (Compcare), and Wisconsin Collaborative Insurance Company (WCIC). BCBSWI underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CM-038847-23
PUBLICATIONS: October 2023 Provider Newsletter
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