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.
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:
NJ, TN, TX
Orientation sessions have now ended. Recordings and program materials are available once logged into the Carelon provider portal.
Email us with questions related to this delegation.
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.
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.
Carelon provider portal: Carelon encourages providers to utilize the online provider portal to submit authorization requests.
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 for the PAC-IM Commercial delegation can be found here.
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:
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