Who is Carelon Medical Benefits Management? How will the program be administered?
Carelon is a leading specialty benefits management company with more than 25 years of experience and a growing presence in the management of cardiology, radiology, genetic testing, oncology, musculoskeletal, sleep management, surgical, and rehabilitation. 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. This program will be administered by Carelon.
What is the Cardiology Program?
The Cardiology Program is a utilization management program that requires providers to request prior authorization for cardiology services. The requests are evaluated against evidence-based, Carelon Clinical Guidelines.
Your participation is required when requesting cardiology services for health plan members. Claims submitted for cardiology services performed on or after the effective date will not be paid if prior authorization has not been obtained through the Cardiology Program.
How does the program benefit my practice and patients?
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 this program already in effect?
Contact your plan for details on program effective date. The Carelon call center and website, Carelon provider portal are available for submission of order requests for cardiology services.
Which modalities require review?
Contact Carelon to obtain pre-service review for the following non-emergency services*:
Implantable Cardiac Devices:
*Note: Procedures reviewed may vary by health plan.
The following are excluded from the Carelon program:
Which health plan members require prior authorization through Carelon?
Please check member benefits and eligibility to determine whether prior authorization is required. Your plan may require clinicians ordering cardiology services to request prior authorization for:
Your request will be reviewed by Carelon, and they will notify you of the decision.
Are your clinical criteria available for review?
Yes, the Carelon Clinical Guidelines are easily accessible online. View Cardiology Clinical Guidelines on the Carelon website.
What methods and resources are used to develop the guidelines?
Development of Carelon Clinical Appropriateness Guidelines involves integration of medical information from multiple sources to support the use of high quality and state-of-the-art cardiology services. The process for criteria development is based on technology assessment, peer-reviewed medical literature, including clinical outcomes research, and consensus opinion in medical practice.
Who develops the clinical criteria for the program?
Carelon Clinical Appropriateness Guidelines are reviewed annually and updated as needed. New and modified guidelines are reviewed by:
In addition, Carelon guidelines are submitted as part of the Carelon accreditation process to the National Committee for Quality Assurance (NCQA) and URAC.
Which devices may require review?
Carelon reviews non-emergent requests for the following devices:
*Note: Procedures reviewed may vary by health plan.
The following are excluded from the Carelon program:
What are the different types of implantable cardiac devices, and which one should be selected?
|Implantable Cardioverter Defibrillator (ICD)||Used to treat ventricular arrhythmias||There are 3 types: transvenous, subcutaneous and substernal.
Do not select for CRT-D device (combined CRT/ICD device)
|Transvenous ICD||The most common type of ICD. Leads go from the generator to the heart via the venous system.||May be single chamber (atrium or ventricle) or dual chamber (atrium and ventricle)|
|Subcutaneous ICD||Type of ICD. There are no leads within the venous system. Instead, the shock travels between the generator placed in the left axilla and an electrode tunneled below the skin to the left of the sternum.|
|Substernal ICD||Type of ICD. Newer device design. The shock travels between the generator placed in the left axilla and an electrode place under the sternum.|
|Cardiac resynchronization therapy (CRT)||Used to make your heart’s chambers squeeze (contract) in a more organized and efficient way.||There are 2 types: CRT-P and CRT-D|
|Cardiac resynchronization therapy combined with pacemaker (CRT-P)||This is a combined CRT/Pacemaker device. Used to treat advanced heart failure.||Also called a biventricular pacemaker. Do not select for CRT-D device (combined CRT/ICD device) or dual chamber pacemaker.|
|Cardiac resynchronization therapy combined with ICD (CRT-D)||This is a combined CRT/ICD device. Used to treat patients with advanced heart failure and are at risk of ventricular arrhythmia.||Also called a biventricular ICD. Do not select for ICD or dual chamber ICD.|
|Pacemaker||Used to treat slow heart rates, heart block, etc.||May be single chamber (atrium or ventricle) or dual chamber (atrium and ventricle). Do not select for biventricular pacemaker device (CRT-P).|
How does Carelon review the cardiac devices?
Implantable cardiac devices are reviewed based on the device indicated (i.e., ICD, CRT-D, CRT-P, or pacemaker) and the episode of care (i.e., initial insertion, upgrade from single to dual chamber, change in device from pacemaker to CRT-P, etc.). The episode of care will include all applicable codes for the device and procedure performed.
How do I participate in the Cardiology 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:
The provider portal support team will then contact the user to finalize the registration process.
What do I need to register?
What does the provider portal allow me to do?
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 requests, we encouraged servicing/rendering providers to verify that prior authorization has been obtained before performing a test 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:
When should providers contact Carelon to request clinical appropriateness review?
Providers should contact Carelon to request clinical appropriateness review and obtain an order number before scheduling or performing any elective outpatient cardiology services.
Does Carelon need to know when the procedure is scheduled?
No, although the order number should be issued prior to scheduling the study and the procedure. Both should occur within the timeframe that the order will remain valid.
What information will Carelon require in order to evaluate a request?
The following information is needed to submit a request to Carelon:
For complex cases, more information may be necessary, including results of past treatment history (previous tests, duration of previous therapy, relevant clinical medical history.
Can we request an urgent authorization?
If you have an urgent request, please contact Carelon at 1-800-252-2021. Urgent requests will receive a response within 72 hours of receipt.
How can providers determine whether an order number has been obtained for a member?
Providers can contact Carelon to determine whether an order number has been obtained for a member covered under the programs.
If a service is already authorized by Carelon and needs to be rescheduled beyond the original [30-60-day] authorization period, is a new order number required?
If the date of the service is extended beyond the original [30 or 60] days, a new authorization must be requested through Carelon.
What happens if a member is approved for a specific procedure and during the course of this procedure, the rendering provider feels that an additional procedure requiring precertification is also needed?
The rendering provider should proceed with the additional procedure. If this occurs, he/she should inform the member’s ordering provider that an additional test was performed on the same day. Carelon must be contacted for an order number for the additional procedure no later than two (2) business days after the services were rendered. The pertinent clinical information supporting the additional procedure must be available at the time Carelon is contacted.
What happens if I do not call Carelon or enter information through the provider portal?
You are encouraged to request prior authorization before the start of services. Retrospective authorization requests may be initiated up to 2 business days after the treatment start date. Failure to contact Carelon for cardiology prior authorization may result in claim denial.
Once I have submitted a request, how long will it take to receive a response from Carelon?
Requests that meet medical necessity criteria: Requests that meet criteria receive a response immediately in the provider portal or on the phone with the Carelon contact center.
Requests that do not meet medical necessity criteria: When an order request cannot be approved immediately, you will have the option of discussing your case with one of our clinical experts. A peer-to-peer discussion with one of Carelon physician reviewers is always offered before any adverse determination is made. No adverse determination is made until the case has been reviewed by a physician reviewer at Carelon.
It is important that when Carelon RN informs your office (always via phone), that the case pends for peer-to-peer conversation, your ordering physician calls Carelon as soon as possible to discuss it with the Carelon physician. Until we receive a phone call back from the ordering physician (or their representative Physician Assistant or Nurse Practitioner), the case will continue to pend. Urgent requests will pend for up to 72 hours of receipt. At that time, if the clinical information requested is not provided and peer-to-peer didn’t take place, the case will be denied. Denial letter will be sent to the member and provider.
How will we know when a peer-to-peer is needed?
When a case pends for review, it will go to an “In Progress” status. Carelon will call the ordering provider requesting a call-back for peer-to-peer review, should it be required.
If the authorization is done via the telephone or via the provider portal, is a letter sent to the provider whether the authorization was approved or denied?
Yes, denial letters will be sent to ordering providers requesting review.
Can an authorization number for a medical necessity determination expire?
Yes, Carelon communicates the expiration date in the approval notification provided for each case.
If a procedure is not approved by Carelon, is there an option to appeal the decision?
Yes, providers may call Carelon within 10 calendar days of a denial decision to request a reconsideration. If a reconsideration request does not lead to an approval, or more than 10 calendar days passed, providers and members can submit 1st level appeals to [Health Plan or Carelon]. Denial letters include appeal instructions for both providers and members.
How do I enter a request on the provider portal?
For step-by-step instructions for submitting a case, go to the Reference Desk in the provider portal.
Why is a duplicate order notification displayed on my order request?
This notification will appear when a similar request is on file or the dates from one order to another order overlap. A Carelon RN will review these cases to verify a duplicate order is not being requested.
Why is my physician showing as out-of-network?
The provider is out-of-network and the benefits may not apply or may be paid at a lower rate. If you believe your provider is in-network, check with your Network Provider representative at your plan to see that your provider is entered into the system as in-network. Provider and member files are sent by your plan to Carelon.
Why is my physician not available for selection in the provider portal?
If your physician is not available for selection, contact provider portal support at 800-252-2021.
What does the Case Status notifications on the Order Summary indicate?
Case Status indicates the overall determination on the request submitted for Carelon review:
What if I can’t find the procedure I’m searching for?
Only procedures managed by Carelon as part of the program can be submitted for review. If you are unable to find the diagnosis in the system, you may call Carelon Customer Service at 800-252-2021 or contact your plan.
Where can I access additional information?
Our provider website offers you all the tools and information you need to get started.
For assistance using the provider portal contact us by email or at 800-252-2021.