Frequently asked questions
Who is Carelon Medical Benefits Management?
Carelon Medical Benefits Management is a leading specialty benefits management company with more than 30 years of experience and a growing presence in the management of radiology, cardiology, genetic testing, oncology, musculoskeletal, sleep management, and specialty drugs. Carelon Medical Benefits Management collaborates with health plans to help improve quality and manage costs for some of today’s most complex tests and treatments. Carelon Medical Benefits Management’s specialty benefits platform powers evidence-based clinical solutions that span specific specialized clinical categories where the health plan has chosen to focus. Carelon Medical Benefits Management offers a robust medical necessity review process that is fully compliant with regulatory and accrediting organizations.
What is the relationship between Carelon Medical Benefits Management and the health plans?
Health plans have contracted with Carelon Medical Benefits Management so they may partner with providers to help manage back pain and related condition treatment options for health plan members.
What is the Healthy Joint and Spine Guide program?
The Carelon Medical Benefits Management Healthy Joint and Spine Guide program is an expansion of the Spine Guide program (launched on July 19, 2021) that supports providers to ensure members receive the care that is appropriate, safe, and affordable. Carelon Medical Benefits Management has created this Healthy Joint and Spine Guide program to promote the most clinically robust care pathways for radiology, musculoskeletal, and rehabilitation services to reduce variation and fragmentation of care delivery. The expanded program will be available beginning July 5, 2023. Carelon Medical Benefits Management’s Healthy Joint and Spine Guide program is a voluntary educational approach that works with providers to:
- Proactively identify members for participation and engagement.
- Promote an appropriate standard of care through the consistent use of evidence-based criteria.
- Direct care to the most clinically appropriate setting.
To which lines of business and states does this apply?
The program will be available on July 5, 2023, for fully insured members (individual, small group, large group) in all Commercial states. The program is also available for three select Anthem National Accounts (ANA) groups.
Why are the health plans implementing the Healthy Joint and Spine Guide program?
Health plans are implementing this program to help providers deliver care for radiology, musculoskeletal, and rehabilitation services that are appropriate, safe, and affordable. Carelon Medical Benefits Management has extensive experience in collaborating with providers so that the right questions are asked to ensure the right care is delivered at the right time.
Is a prior authorization required?
No, prior authorization is not required.
Who is Livara?
Livara is a digital care management platform that provides a whole health approach to orthopedic care. This platform predicts and qualifies the clinical risk factors to have the biggest impact on the member’s recovery, such as activity, body habits, core muscle strength, function, general habits, medication usage, muscular weakness and imbalance, nerve irritation, pain level, and posture. Based on a continuous flow of data from the member and clinician, the Livara care team can quickly make adjustments to its treatment course based on progress, or lack thereof.
How does the program work?
- Livara unifies the patient experience with an individual risk score and customized care pathway.
- Matches a member with a personal coach to customize treatment before, during, and after an acute episode occurs
- Offers a full range of integrated programs — including nutrition, mindfulness, addiction services, and sleep counseling — to address the complicated physical and behavioral factors that lead to chronic pain
Note: Program specifics may vary by health plan. Please verify or check with the patient’s health plan if you have any questions.
What happens if a member does not want to participate?
This program is completely voluntary.
Benefits of the Carelon Medical Benefits Management Healthy Joint and Spine Guide program:
- Supports members with chronic, long term back or joint pain
- Minimizes unnecessary procedures
- Reduces recurrences and additional procedures
- Reduces complications
- Reduces the need for opioid prescriptions
- Lowers total episodic cost of care
- Lowers out-of-pocket costs for members
- Increases productivity (fewer missed workdays, lowered absenteeism)
What happens if the member is not improving clinically?
For commercial, fully insured members, the health plan may coordinate with other members of the patient’s care team. When a member has opted into the Healthy Joint and Spine Guide program and they are not improving clinically, not responding to the exercise plan, or their pain is getting worse, Carelon Medical Benefits Management directs the member to reach out to their healthcare provider for further support and assistance.
Does the program have a cost?
No, there is no cost for this program; health plans typically offer the Healthy Joint and Spine Guide program as part of the member’s health plan coverage.
Why Carelon Medical Benefits Management is different:
- When musculoskeletal invasive procedures are determined to be the best path forward, the prior authorization process will be coordinated by Carelon Medical Benefits Management.
- A computer, tablet, or iPhone is all that is needed to access the platform.
- Carelon Medical Benefits Management has the ability to identify members early based on claims, authorization history, and risk factors.
Where can I access additional information?
For more information: Our dedicated Healthy Joint and Spine Guide provider website offers you all the tools and information you need. To access, go to: www.providers.carelonmedicalbenefitsmanagement.com/backpain/
Note: These questions are not specific to any health plan, if you have further questions about a particular health plan’s program, please coordinate those questions with your health plan representative.