Anthem
Carelon Post Acute Solutions | PAC-IM Program
Carelon is proud to announce its partnership with Anthem, Inc. to provide utilization management for in-patient post-acute services in the states of CA, CO, CT, GA, KY, IN, ME, MO, NH, NJ, NM, NV, NY, OH, TN, TX, VA, WA, and WI. Please find important announcements, documents, and forms listed below.
Current announcements
NJ,NY,TN,TX | Delegation information
Delegation:
Effective March 1, 2023, Carelon began managing in-patient post-acute care services in the states of NJ, NY, TN, and TX. Delegated services include Utilization Management.
Notice: The delegation notice and orientation letter mailed to facilities is available below by market:
NY
NJ, TN, TX
Orientation sessions:
Orientation sessions have now ended. Recordings and program materials are available once logged into the Carelon provider portal.
Contact:
Email us with questions related to this delegation.
Provider information form
PAC-IM Facilities (SNF, IRF, LTACH only): Please ensure you are registering for the portal under the “Post-Acute Facility” option. If your facility information is not available in the Carelon portal, please complete the “Provider information form” found online here.
Authorization program materials
In-scope plans:
In-scope plan list: The list of in-scope plans, including the September 1st states.
Fax confirmation form: Online Form providers use to confirm their fax numbers for authorization requests.
Authorization requests
Carelon provider portal: Carelon encourages providers to utilize the online provider portal to submit authorization requests.
Fax request forms
Initial and continued stay request fax forms can be found below by setting type:
Fax forms for Skilled Nursing Facilities (SNF):
SNF initial request fax form
SNF continued stay request form
Fax forms for inpatient rehabilitation facilities (IRF):
IRF initial request fax form
IRF continued stay request form
Fax forms for Long-Term Acute Care Hospitals (LTACH):
LTACH initial request fax form
LTACH continued stay request form
Clinical guidelines
Clinical guidelines for the PAC-IM Commercial delegation can be found here.
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: 833-311-2986
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.