Frequently asked questions
What is the Additional Outpatient Utilization Management (AOPUM) program?
The Carelon Medical Benefits Management AOPUM Program is here to support you in helping your patients receive the care that is appropriate, safe, and affordable. Through impactful communication and education about the program, we are poised to engage you and your office support staff in the management of the complexities associated with transportation and additional outpatient services. We have developed an approach that works with you to:
- Promote standard of care through consistent use of evidence-based criteria
- Direct care to the most clinically appropriate form of transportation
Your patients’ health plan is implementing the program to help you in your efforts to ensure your patients receive care that is appropriate, safe, and affordable – and delivers improved results for your practice too.
Asking the right questions leads to delivering the right answers at the right time to your patients.
How will the program be administered?
The AOPUM Program will be administered by Carelon on behalf of your patients’ health plan. Participating in the Program is most easily managed using the Carelon Provider Portal™, available 24 hours a day, 7 days a week.
Who is Carelon?
Carelon is a leading specialty benefits management company with more than 25 years of experience and a growing presence in the management of radiology, cardiology, genetic testing, oncology, musculoskeletal, sleep management, rehabilitation, transportation and additional outpatient services. Our mission is to help ensure health care services are more clinically appropriate, safer, and more affordable. We promote the most appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services.
How does Carelon work with health plans?
Carelon collaborates with health plans to help improve health care quality and manage costs for some of today’s complex tests and treatments, working with physicians like you to promote patient care that’s appropriate, safe, and affordable. In partnership with health plans, we are fully committed to achieving their goals – and yours – to improve health outcomes and reduce costs. Our powerful specialty benefits platform powers evidence-based clinical solutions that span the specialized clinical categories where a health plan has chosen to focus. Our robust medical necessity review process is fully compliant with regulatory and accrediting organizations, while offering a superior experience for you and the health plan’s providers and members.
Is the program already in effect?
Contact your plan for details on program effective date. The Carelon call center, website, and Carelon Provider Portal™ are available for submission of order requests for AOPUM services.
Which modalities require review?
Contact Carelon to obtain pre-service review for the following services:
Transportation:
- Non-emergent ground (including domestic and international transportation)
Additional Outpatient:
- Nutrition
- Hematology
- Neuromuscular
- Other Miscellaneous Procedures
Which health plan members require prior authorization through Carelon?
Please check member benefits and eligibility to determine whether prior authorization is required.
How do I participate in the AOPUM Program through Carelon?
The best way to submit a review request is to use the Provider Portal™.
Provider Portal™ allows you to start a new order, update an existing order, and retrieve your order summary. As an online application, provider portal is available 24 hours a day, 7 days a week.
Your first step is to register your practice in provider portal – if you are not already registered. Go to www.providerportal.com to register. If you have previously registered for other services managed by Carelon (e.g. radiology, genetic testing, radiation therapy), there is no need to register again.
Is registration required on provider portal?
Each member of your staff who enters review requests will need to register. Here is how to do it:
- Step one: Go to providerportal.com and select “Register Now” to launch the registration wizard
- Step two: Enter user details and select user role as “ordering provider”
- Step three: Create username and password
- Step four: Enter the tax ID numbers for your providers
- Step five: Check your inbox for an email from Carelon. Click on the link to confirm email address
The provider portal support team will then contact the user to finalize the registration process.
What info do I need to register?
- Your email address
- The tax ID number for the providers whose orders you will be entering
- Your phone and fax number
What does the provider portal™ allow me to do?
- Submit a new order request
- Update an existing order request
- Retrieve your order summary
Will members be able to contact Carelon?
Members should contact their plan directly if they have any questions.
Who can submit review requests?
Ordering providers and their staff members may submit review requests. When the Ordering provider submits an order request, we encourage servicing/rendering providers to verify that prior authorization has been obtained before performing a service for a plan member. Providers can verify prior authorization using provider portal.
How does a physician office staff member obtain an order number from Carelon and request clinical appropriateness review?
There are two ways providers can contact Carelon to request review and obtain an order number:
Online
- Get fast, convenient online service via the provider portal (registration required). Provider portal is available 24 hrs/day, 7 days/week. Go to providerportal.com to begin.
By phone
- If you need any help using the provider portal, call provider portal support at 1-800-252-2021.
How will I know if my order request met clinical criteria and was approved?
Your office – the office of the ordering physician, submits order requests through the provider portal – our interactive internet application – or through the Carelon contact center. Web users and callers will be guided through an interview where member and ordering/servicing physician information, procedure code and diagnosis, origin & destination locations (for transportation), etc. will be requested.
If the information provided meets the clinical criteria, an order number will be issued.
If all criteria are not met or additional information or review is needed, the case is forwarded to a registered nurse (RN) who uses additional clinical experience and knowledge to evaluate the request against the clinical criteria. The nurse reviewer has the authority to issue order numbers in the event that he or she is able to ensure that the request is consistent with clinical criteria.
If an order number still cannot be issued by the nurse reviewer, they will contact you to schedule a peer-to-peer discussion with a Carelon physician reviewer (MD). The physician reviewer can approve the case based on a review of information collected or through their discussion with the ordering clinician.
In the event that the Carelon physician reviewer cannot approve the case based on the information previously collected, is unable to reach you to discuss the case, or is unable to approve the case based on the information supplied by you during the peer-to-peer discussion, the physician reviewer will issue a denial for the request.
How long does my patient’s approval last?
Unless otherwise required by state law, approvals are valid for 60 calendar days. Carelon communicates the expiration date in the approval notification for each case.
Can an authorization number for a medical necessity determination expire?
Yes. Carelon communicates the expiration date in the approval notification provided for each case.
What are my options if a review request does not meet clinical criteria?
Your office can contact Carelon to request a peer-to-peer discussion at any time before or after the determination. When there is a request for a peer-to-peer consultation, we will make an effort to transfer the call immediately to an available Carelon physician reviewer. When a physician reviewer is not available, we will offer a scheduled call back time that is convenient for the practice.
After you receive notice of a denial, the provider has two options for further review at Carelon. One is to ask for a reconsideration of the decision within 10 days of the denial. This gives the provider an opportunity to provide additional information to one of our physician reviewers who will have the authority to overturn the denial. If you choose not to pursue a reconsideration, the other option is to submit documentation in support of your request through the document upload feature on the provider portal.
Where can I access additional information?
For more information: Our dedicated Musculoskeletal provider website offers you all the tools and information you need. To access, go to providers.carelonmedicalbenefitsmanagement.com/additionalopum