Frequently asked questions

How does the Musculoskeletal Program work?
Through our program, we are here to assist you and other participating providers. You contact Carelon to request a review of certain surgeries and interventional pain management treatments. We review complex surgeries and interventions in the inpatient and outpatient settings against evidence-based clinical guidelines to ensure care is medically necessary according to medical evidence. We also assist you in reviewing the site of care you request to make sure that it’s appropriate for your patient’s procedure based on their specific clinical circumstances.

When the care requested does not meet clinical criteria, our established staff of spinal surgeons, anesthesiologists, orthopedic surgeons, neurosurgeons, and pain management physicians provide peer-to-peer consultation.

Are your clinical criteria available for review?
Yes, the Carelon Clinical Guidelines are easily accessible online. See Clinical Guidelines. You can also find these within the provider portal when clinical review requests are initiated.

What kind of cases are reviewed for clinical site of care review process?
We review complex surgeries and interventional pain management in the inpatient and outpatient settings against evidence-based clinical guidelines to help reduce inappropriate care, overtreatment, and excessive costs, while helping to ensure appropriate, safe, and affordable care. Our established staff of spinal surgeons, anesthesiologists, orthopedic surgeons, neurosurgeons, and pain management physicians provide peer-to-peer engagement.

We review the following procedures and treatments:

• Spinal surgery – Spine Surgery – Cervical, thoracic, lumbar, sacral and sacroiliac joint fusion
• Joint surgery
• Interventional pain management

How do I participate in the Musculoskeletal Program through Carelon?
The best way to submit a review request is to use the provider portal.

Provider portal allows you to open 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 (diagnostic imaging, radiation therapy), there is no need to register again.

Is registration required at provider portal?
Each member of your staff who enters review requests will need to register. Here’s how to do it:

• Step one: Go to www.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 user name 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 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

The provider portal allows you to:

• Submit a new order request
• Update an existing one
• Retrieve your order summary

Which procedures require review?
Acute fractures or trauma and neurological conditions that present in the emergency room do not require preauthorization.

Note: Preauthorization is required for notification purposes only (medical necessity review is not required) when CPT 62320 and 62322 are used for post-procedural pain with any of the following ICD-10-CM diagnoses: G89.11 (acute pain due to trauma), G89.12 (acute post-thoracotomy pain) or G89.18 (other acute post-procedural pain).

ICD-10-CM

G89.11 Acute pain due to trauma
G89.12 Acute post-thoracotomy pain
G89.18 Other acute post procedural pain

Contact Carelon to obtain pre-service review for the following non-emergency modalities:

Spine Surgery – Cervical, thoracic, lumbar, sacral and sacroiliac joint fusion

• Automated percutaneous and endoscopic discectomy
• Bone grafts
• Bone growth stimulators
• Cervical/lumbar spinal fusions
• Cervical/lumbar spinal laminectomy
• Cervical/lumbar spinal discectomy
• Cervical/lumbar spinal disc arthroplasty (replacement)
• Sacroiliac joint fusion
• Spinal deformity (scoliosis/kyphosis)
• Vertebroplasty/kyphoplasty

Joint surgery (including all associated revision surgeries)

• Total hip replacement
• Total knee replacement
• Shoulder arthroplasty
• Hip arthroscopy
• Knee arthroscopy
• Shoulder arthroscopy
• Small joint surgery
  • Total ankle replacement
  • Hammertoe correction
  • Bunionectomy
  • Hallus rigidus
  • 1st toe arthrodesis

Interventional pain management

• Epidural adhesiolysis
• Epidural injections (interlaminar/caudal and transforaminal)
• Facet joint injections/ medial branch blocks
• Facet joint radiofrequency nerve ablation
• Implanted spinal cord stimulators
• Regional sympathetic blocks
• Sacroiliac joint injections
• Thermal intradiscal procedures

CPT Codes
See the billing codes for the procedures we review

Note: procedures reviewed may vary by health plan.

How does Carelon make alternate site-of-care recommendations?
Preferred facilities are identified by your patient’s health plan.

Does the program include inpatient services?
Yes, the program includes all procedures regardless if they are performed on an inpatient or outpatient basis.

How do I use the provider portal to submit my treatment?
Once registered, log in to the provider portal to begin the order entry process. You will be guided through a series of questions regarding your patient, the requested procedure, and your patient’s clinical condition.

What information do I need to submit to Carelon?
Our simple checklists show exactly what information you will need.

What happens if I do not call Carelon or enter information through the provider portal?
If you call the health plan directly, you will be directed to the provider portal or to call the Carelon contact center.

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 physician information, diagnosis, symptoms, exam type, and treatment/clinical history will be requested.

If the information provided meets the Carelon clinical criteria and is consistent with the health plan’s medical policy, the web user/caller will then be guided to select a provider where the surgery or pain management will be performed, and 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) or a physical therapist who uses additional clinical experience and knowledge to evaluate the request against clinical guidelines. 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 our clinical criteria and health plan medical policy.

If an order number still cannot be issued by the nurse or physical therapist reviewer, they 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 surgeon.

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, spine and joint surgeries are valid for 60 calendar days. Pain management approvals are for 10 business 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 www.carelonprovider.com/msk

What is the Musculoskeletal Clinical Site of Care review? How does it benefit health plan members?
The Musculoskeletal Clinical Site of Care review process is intended to support you in helping patients receive care that is appropriate, safe, and affordable. Certain musculoskeletal procedures will require additional review if performed in an outpatient hospital setting.

In some plans terms such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of service” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use, “site of care”.

How does the Musculoskeletal Clinical Site of Care review process work?
When your practice submits a request for authorization and selects a hospital-based outpatient facility as the site of care for certain musculoskeletal procedures, you will be prompted to indicate the reason a hospital-based site of care is medically necessary. If a request for hospital-based site of care does not meet medical necessity criteria, the request will not be approved.

Which musculoskeletal services are reviewed for clinical site of care?
See Resources for applicable procedures. This review applies for musculoskeletal procedures scheduled to be performed in a hospital-based setting. Services performed in an emergent setting do not require review.

Where can providers find the clinical guideline that will apply to the Musculoskeletal clinical site of care review?
When applicable, your patient’s health plan can provide clinical guidelines for clinical site of care review. For your convenience we have provided links to these guidelines here.

How will the review be administered?
The Musculoskeletal Clinical Site of Care review is administered by Carelon on behalf of your patients’ health plan. Participation in the program is most easily managed using the provider portal, available 24 hours a day, 7 days a week.

Carelon conducts reviews of certain musculoskeletal services against health plan medical policies and clinical guidelines. Review for clinical appropriateness of the site of care will be provided by a Carelon physician reviewer if the service is in scope for this site of care review and the outpatient hospital setting is selected. Note for some services, both the musculoskeletal service and the site of care must meet the respective clinical criteria in order for an approval to be issued.

If I select an appropriate site of care location when submitting an authorization request, will the request be reviewed for site of care?
If the prescribing physician selects a facility other than an outpatient hospital, additional clinical review for site of care will not be required.

Alternate Site of Care Locations

Which participating providers’ locations are considered alternates to an outpatient hospital?
Alternate providers may include licensed ambulatory surgery centers (ASCs) or physician office-based suites. Members and providers are encouraged to use the member’s health plan website to identify participating providers in advance of any service.

Patient information and impact 

What if the nearest network ambulatory surgery center is a long distance for the patient to travel or does not have equipment for the planned procedure?
Both geographic access and resource availability will be taken into account in the clinical site of care review process. If your patient does not have geographic access to a network, ambulatory surgery center with the necessary resources to perform the procedure, the procedure can be authorized at a network outpatient hospital site of care.

If I do not have privileges at an ambulatory surgery center, what steps can I take?
We encourage providers to review the network ambulatory surgery centers in their area and obtain privileges with those centers that best meet the provider and members’ needs. The clinical guideline provides criteria for review of the clinical appropriateness of the hospital outpatient site of care (location). Physician privileging at alternate sites of care may be taken into consideration during the review. Please be aware that this is managed by each health plan. Some plans may allow a grace period to provide time for physicians to gain privileges at ambulatory surgery centers.

Whom do I contact if I have questions?
Please contact your local network management representative or call the customer service phone number on the back of your patient’s health care identification card.

Please feel free to download our full FAQ document.

This document is 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.