Carelon Post Acute Solutions is proud to announce its partnership with Aetna to provide utilization management for home health services in Georgia, Kentucky, Missouri, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, and West Virginia. Please find important announcements, documents, and forms listed below.
Delegation: Effective July 1st, 2023, Carelon will manage Aetna Medicare Advantage (MA) plans in the state of Florida. Delegated services include Utilization Management, Network Management, and Claims Reimbursement.
Notice: The delegation notice is available here.
Please complete the “Agency information form” to have your agency’s information added to the Carelon system. The form is found online here.
In-scope plan list: The list of in-scope Aetna plans for the Carelon delegation.
Provider portal: Carelon encourages providers to utilize the online Provider portal to submit authorization requests. The Provider portal can be found online here.
Initial authorization request form: Fax form to use for initial authorization requests if needed.
Re-authorization request form: Fax form to use for re-authorization requests if needed.
Fax confirmation form: Online form providers use to confirm their fax numbers for authorization requests.
Home infusion (IV) therapy:
Home infusion (IV) therapy information: Carelon is not delegated for IV Therapy. This document explains the IV therapy program in detail.
The Carelon payer ID for the Aetna delegation is: 34010. Please find important forms related to the Carelon Claims Process listed below.
Electronic funds transfer (EFT) enrollment:
Carelon offers EFT payment options for providers. To enroll in the EFT program, please register for EFT payments by completing the online application form:
EFT application form
Payment dispute request form in-network providers
Payment dispute request form out-of-network providers
Claims waiver of liability form for out of network providers
Please contact the Carelon claims team for questions related to the claims process by calling 833-241-0428.
If you are an existing Carelon Participating Provider and need to update any of your Provider Information (i.e. NPI, address, or phone), please submit the Provider change form found below.
Provider change form: Online form providers use to update information.
Please find the contracting form here.
If Carelon Post Acute Solutions accepts your provider contracting application, you will need to complete the appropriate credentialing application.
Please download the credentialing application found below, complete, and return to our Credentialing team by email or via fax at (615) 724-7468. Carelon evaluates provider qualifications based on the Utilization Review Accreditation Commission (URAC) requirements.
Download a copy of the application packet here:
Credentialing application and criteria packet
Carelon utilizes CMS National and Local Coverage Determinations (NCD and LCDs) when applicable, or Aetna medical policies and clinical Utilization Management guidelines to facilitate the appropriate evaluation of medical necessity by including assessment of the member throughout the continuum of care. A synopsis of the criteria is available to Providers and Members on request and free of charge by calling Carelon at 833-585-6262 or by email.
Please contact the Carelon provider network team with any questions by email or:
An individual shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination on the grounds prohibited under Title VI of the Civil Rights Act of 1964, 42 USC § 2000d et seq. – PDF (race, color, national origin, sex, age, sexual orientation, gender identity, and disability), Title IX of the Education Amendments of 1972, 20 USC § 1681 et seq. – PDF (sex), the Age Discrimination Act of 1975, 42 USC § 6101 et seq. (age), or Section 504 of the Rehabilitation Act of 1973, 29 USC § 794 – PDF (disability), under any health program or activity, any part of which is receiving Federal financial assistance, or under any program or activity that is administered by an Executive Agency or any entity established under Title I of the Affordable Care Act or its amendments. OCR has enforcement authority with respect to health programs and activities that receive Federal financial assistance from the Department of Health and Human Services (HHS) or are administered by HHS or any entity established under Title I of the Affordable Care Act or its amendments. Carelon Post Acute Solutions employs industry standard information security systems including, but not limited to: Unified Threat Management (UTM), Vulnerability Threat Management (VTM), Data Loss Prevention (DLP), and Security Information and Event Management (SIEM), Email Encryption, and Secure Sockets Layer (SSL) certificates. Inquiries regarding Carelon’ information security and privacy policies, procedures or activities may be directed to the Privacy Team through email.