Frequently asked questions

What do you mean by Cancer Treatment Pathway?
Pathways are widely accepted as a component in managing oncology treatment quality and costs. More specific than guidelines, pathways identify treatments selected based on effectiveness, favorable toxicity profiles, and cost. Over half of practices responding to ASCO’s 2010 National Practice Benchmark report that they regularly use pathways in patient care. Organizations that have implemented pathways have found that survival outcomes are equivalent for patients treated on and off pathway, while treatment costs decrease substantially for patients treated on pathway.

How were the Cancer Treatment Pathways developed?
The goal of the Cancer Care Quality Program is to promote access to quality and affordable cancer care for health plan members. A key component of the Cancer Care Quality Program is the development of the Carelon Cancer Treatment Pathways.

Cancer Treatment Pathways are developed using a rigorous process of evidence-based medicine. In order to be considered as a possible Cancer Treatment Pathway, a cancer treatment regimen must first be recognized by national guidelines as an effective and recommended cancer therapy.

The Pathways are developed starting with the medical evidence and national clinical guidelines, such as NCCN and ASCO guidelines, which also are used for developing Carelon medical policy. The Pathways are then reviewed by an external Advisory committee that consist of geographically diverse physicians who are actively treating patients and work in academic and community oncology groups. The committee uses a process similar to how we evaluate drugs chosen for our drug formularies. The group evaluates the evidence for given treatments and compares outcomes for each – much like a comparative effectiveness review. Then, they compare costs of those regimens with the best outcomes.

How are Carelon’s external Advisors selected? 
Our advisors are selected because of their clinical expertise in cancer care. Of the physicians currently serving as advisors for Carelon, some are on the staffs of NCI or NCCN designated cancer centers, including Cleveland Clinic, Columbia, Fred Hutchinson, University of Colorado, and Yale and some are in community practice settings; many serve or have served on national committees for organizations such as NQF, ASCO, FACT, and IOM to improve cancer care.

Does Carelon have a process to manage conflicts of interest for external Advisors?
Carelon is committed to having clinical experts free of commercial bias and conflicts of interest determining which treatment regimens to be included in Pathways. Upon agreeing to serve as advisors for Carelon, advisors must sign a formal Agreement that outlines the responsibilities, including an acknowledgment that advisor has no conflict of interest. Advisors also agree to notify Carelon immediately of the existence of any conflict of interest. Additionally, advisors must sign a new conflict of interest attestation, at least once annually.

The Cancer Treatment Pathways are selected on the basis of:

• Clinical benefit (efficacy)
• Side-effects (toxicity), especially those that lead to hospitalizations or impact quality of life
• Strength of national guideline recommendations
• Cost

Cost is considered only after consideration of all other factors in selecting a therapy as a Cancer Treatment Pathway

Where can I find a copy of the Cancer Treatment Pathways?
The pathways are posted on www.cancercarequalityprogram.com. On this website you can find information, tools and worksheets to assist you in incorporating the Cancer Care Quality Program into your practice.

What if I am treating a patient for whom a Pathway regimen option is not available?
Cancer Treatment Pathways include multiple regimens for different clinical situations. However, if a Pathway regimen is not available for a particular type of cancer or line of therapy, you can select a different regimen. Please note that enhanced reimbursement is only available for designated Cancer Treatment Pathways.

Do Pathways apply to pediatric patients?
The Cancer Care Quality Program only applies to adult oncology patients at this time. However, you are encouraged to enter regimens for all malignancies into the ProviderPortal.

What happens if I do not select a treatment regimen that is designated as a Cancer Treatment Pathway?
If you are an in-network provider for the member’s benefit plan and you do not select a Cancer Treatment Pathway, you will not be eligible for the enhanced S-code reimbursement. The requested treatment regimen will continue to be reviewed through the usual utilization management review process if UM is required and/or adjudicated according to the member’s benefit plan.

How often are the Cancer Treatment Pathways updated?
Cancer Treatment Pathways are reviewed at least quarterly or more frequently, as needed.

Are supportive drugs included in the Pathways?
Supportive care drugs, such as those used to manage side effects of chemotherapy, are not currently included in the Cancer Treatment Pathways. However, the entire cancer treatment drug regimen, including supportive care drugs, should be included in the order request as certain supportive drugs may be included on the list of drugs that require utilization management review against applicable health plan medical policies or clinical guidelines. This list has not changed with the introduction of the Cancer Care Quality Program.

What should I do if the drugs I am ordering require prior authorization/precertification under my patients’ pharmacy benefits?
Please contact the patient’s Pharmacy Benefit Administrator for any necessary Pharmacy Plan authorizations or pre-certifications required.

What is Carelon Specialty Health and what is its role in the Cancer Care Quality Program?
The Cancer Care Quality Program will be administered by Carelon Specialty Health on behalf of your patients’ health plans. Carelon Specialty Health, a separate company, collaborates with payors to help improve healthcare quality and manage costs for some of today’s complex tests and treatments, promoting patient care that’s appropriate, safe and affordable.

How do I participate in the Cancer Care Quality Program through Carelon?
Participating in the Cancer Care Quality Program can be a straightforward process and is most easily managed using the ProviderPortal.
ProviderPortal allows you to open a new order, update an existing order and retrieve your order summary. As an online application, ProviderPortal is available 24/7. Your first step is to register your practice in ProviderPortal, if you are not already registered.

Online:
Get convenient online service via the ProviderPortal (registration required). ProviderPortal is available twenty-four hours a day, seven days a week, processing requests in real-time. Go to https://providerportal.com to register. If you have previously registered for other services managed by Carelon (diagnostic imaging, radiation therapy, specialty drugs), there is no need to register again.

By phone:
Call Carelon Specialty Health toll-free at the following phone numbers and times:

Carelon Contact Center Information:

How do I use the ProviderPortal to submit my cancer treatment?
A step-by-step tutorial on using the ProviderPortal to submit your regimen can be accessed
online by going to www.cancercarequalityprogram.com

Once I have submitted a request, how long will it take to receive a response from Carelon?
Requests that meet criteria receive a response instantly on screen in the ProviderPortal or on the phone with
the Carelon contact center.

If I am in-network provider for the member’s benefit plan and I select a Cancer Treatment Pathway, how will I be notified of the enhanced reimbursement?
When selecting a Cancer Treatment Pathway regimen, you must use either the ProviderPortal or phone. In both instances, you will be notified immediately after selecting a Pathway regimen that you are eligible for . A separate letter will not be provided. It is recommended that you save the summary page that you receive from the ProviderPortal after completing your initial order in your patients’ chart.

What happens if I do not call Carelon or enter information through the ProviderPortal?
If you call the health plan directly, you will be directed to use the ProviderPortal or call the Carelon contact center. If you do not provide Carelon with the necessary information, you will not be eligible for enhanced reimbursement, even if the treatment regimen is on Pathway. In addition, if any oncology drugs are subject to health plan Medical Policy or Clinical Guidelines and have not been reviewed prospectively, they may be subject to post-service review.

What if I need a longer treatment period than is indicated in the Cancer Treatment Pathway?
The Cancer Treatment Pathway reflects an expected duration of treatment. For a regimen (e.g., adjuvant therapy) of fixed duration, the Pathway enhanced reimbursement is for the duration of all planned cycles of chemotherapy. For a treatment regimen that is indefinite (e.g., planned until disease progression), the Pathway enhanced reimbursement is for 6 months. If treatment continues beyond 6 months, please submit a new treatment regimen request to Carelon. Most users will find the most efficient way to track the Pathway time period is to save the summary page that you receive from the ProviderPortal after completing your initial order in your patients’ charts so that the information to report continuation of treatment is easily available.