Anthem

Carelon Post-Acute Care | Home Health Program

Carelon Medical Benefits Management is proud to announce its partnership with Anthem, Inc. to provide utilization management for home health services. Please find important announcements, documents, and forms listed below.

Current announcements

New Jersey | March 1st, 2023 delegation information

Contracting: To become a Carelon contracted provider, please complete the form found online here.
Delegation: Effective March 1st, 2023, Carelon began managing Amerigroup Medicare Advantage (MA) plans in the state of New Jersey. Delegated services include Utilization Management, Network Management, and Claims Reimbursement.
Notice: The delegation notice and orientation letter mailed and emailed to agencies is available here.

Agency information form

Please complete the “Agency Information Form” to have your agency’s information added to the Carelon system. The form is found online here.

Authorization program materials

In-scope plans:
In-scope plan list: The list of in-scope Anthem plans for the Carelon delegation listed by state. Please note Risk plans are not included in this delegation.

Authorization requests:
Carelon 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 Based IV Therapy:
-Carelon does manage infusion (IV) requests if the agency has an unbundled IV billing status.
-An agency is considered unbundled per IV billing status when IV SN visits are billed to the member’s insurance for reimbursement.
-An agency is considered bundled if IV SN visits are billed to the DME/Infusion company (supplying the member).
-If you are considered bundled, but the SN is performing other skilled services (i.e. wound care, COPD care, diabetic management, etc.) then you would still submit an authorization request for those -SN services.
-IV skilled nursing reviews are based on medical necessity, caregiver’s ability/willingness, and the member’s medical conditions.
-If you are ever in doubt, please submit a request through the Provider Portal, and our reviewers will let you know.

Claims program materials

The Carelon payer ID for the Anthem delegation is: 34009. 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

Claims forms:
Claim appeal request form in-network providers
Claim appeal 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.

Provider information updates

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.

Additional resources

• Anthem code of conduct
• Provider portal login
• Publications
• Provider communications-CA
• BCBSGA
• Amerigroup WA
• Amerigroup TX
• Amerigroup NM

Contact us

Carelon utilizes CMS National and Local Coverage Determinations (NCD and LCD’s) when applicable, or Anthem 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 844-411-9622 or by email.

Please contact the Carelon provider network team with any questions by email or:

Phone: 844-411-9622
Fax: 844-834-2908

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.