Carelon Medical Benefits Management 

Overview

Carelon is a specialty health benefits company that works with leading insurers to improve health care quality and manage costs for today’s most complex and prevalent clinical guidelines, tests and treatments, helping to promote care that is appropriate, safe and affordable.

Carelon provides prior authorization, recommended clinical review, advanced imaging site of care and post service medical necessity review for certain outpatient services and plan members.

Be sure to check eligibility and benefits though Availity® Essentials or your preferred vendor to determine if a prior authorization is required, if RCR  or advanced imaging site of care is applicable for the patient depending on their benefit plan.

Carelon Prior Authorization and Recommended Clinical Review Program

Carelon provides required prior authorization review and RCR for select outpatient services for some members of the following plans:

  • Blue Choice PPOSM
  • Blue EssentialsSM
  • Blue PremierSM and Blue Premier AccessSM
  • Blue Advantage HMOSM
  • MyBlue HealthSM
  • Blue High Performance Network®
  • Teacher Retirement System of Texas participants
  • Employees Retirement System of Texas participants 

With Carelon administering prior authorizations, we can optimize our programs, further ensuring that care aligns with established evidence-based medicine.

Effective Jan. 1, 2025, Carelon will do a medical necessity review including site of care when you request eligible computed tomography, computed tomography angiography, magnetic resonance imaging and magnetic resonance angiography imaging services that require a prior authorization or are applicable for a recommended clinical review in a hospital-based outpatient setting for certain commercial members.

Outpatient Services Impacted for Carelon Reviews

For services noted below select the category on the Carelon website.

  • Cardiology 
  • Genetic Testing 
  • Joint and Spine Surgery, and Pain Management 
  • Medical 
  • Oncology  
  • Radiation Therapy 
  • Radiology 
  • Sleep

Reminders

  • Providers need to determine if prior authorization is required or RCR is available through Carelon before rendering services. Services can vary depending on the patient benefits.
  • Ordering physicians or servicing providers (facilities) may submit prior authorization requests.
  • For joint and spine surgery prior authorizations or RCRs, if an outpatient or inpatient facility stay is being requested, providers will contact Carelon first for medical necessity determination, then contact BCBSTX for final determination of length of stay & the level of care.
  • Payment may be denied if procedures are performed when prior authorization is required and health care providers may not bill the patient.

Benefits of the Carelon ProviderPortal for Pre & Post-Service Reviews:

  • Offers self-service, smart clinical algorithms and in many instances real-time determinations
  • Check prior authorization status
  • Increases payment certainty
  • Provides faster pre-service decision turnaround times than post service reviews
  • Medical records for pre or post-service reviews are not necessary unless specifically requested by Carelon.

Submitting Requests to Carelon

Attend free training sessions on how to submit requests for Carelon Prior Authorizations or RCRs. Refer to the Carelon On-demand training page for available sessions.

Information Needed

Ensure you have all the following before requesting a Prior Authorization or RCR from Carelon:

  • Patient’s identification number, name and date of birth
  • Ordering physician's or professional provider's name, address and telephone
  • Imaging provider information (name, location)
  • Imaging exams being requested (body part, right, left or bilateral)
  • Patient diagnosis (suspected or confirmed)
  • Genetic test name (when applicable)
  • Clinical symptoms
  • Additional information may be necessary for complex cases including results of past treatment history (previous tests, duration of previous therapy, relevant clinical medical history)

Submission Methods

Providers are encouraged to utilize the Carelon ProviderPortal for the most efficient method to submit requests.

  • Online: Log in to the Carelon ProviderPortal Available 24/7/365
  • Phone: 1-800-859-5299
    Monday – Friday, 6 a.m. to 6 p.m. CT, Saturdays, Sundays and Holidays, 9 a.m. to noon CT
  • Fax: 1-800-610-0050
    Note: Fax option is available only for physicians or professional providers who are submitting clinical information for existing requests.

Request Process

  • Do not submit medical records unless requested by Carelon.
  • Based on clinical criteria, Carelon will issue a prior authorization or forward the case to a nurse or physician for review.
  • The physician reviewer may contact the ordering physician to discuss the case in greater detail within 2 business days of receipt of the request.
  • Ordering physician or professional providers may also contact Carelon's physician reviewer at any time during the review process.
  • If criteria are not met or additional information is needed, the case will be automatically transferred for further clinical evaluation.
  • When criteria are met, Carelon will provide an approved request order number, which will include the dates it is valid.
  • This is not a guarantee of payment. The claim will be processed in accordance with the terms of a member/participant's health benefit plan. Requests will be directed to the most cost-effective outpatient providers to maximize benefits.

Notes:

  • Health care providers who are contracted/affiliated with a capitated IPA/Medical Group must contact the IPA/Medical Group for instructions regarding referral, RCR and prior  authorization processes. Additionally, health care providers who are not part of a capitated IPA/Medical Group but who provide services to a member/participant whose PCP is contracted/affiliated with a capitated IPA/Medical Group must contact the applicable IPA/Medical Group for instructions.
  • For BlueCard® members, please contact Customer Service utilizing the phone number on the back of the ID card to determine if the Carelon prior authorization applies.

 

Carelon Medical Benefits Management is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity or Carelon Medical Benefits Management. 

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or has a recommended clinical review for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.