About Carelon Medical Benefits Management

About Carelon Medical Benefits Management

Carelon is a leading specialty benefits management company with more than 30 years of experience. Our mission is to help ensure delivery of health care services are more clinically appropriate, safer, and more affordable. We promote the most appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services.

Upcoming Carelon MBM clinical appropriateness guidelines and cancer treatment pathways updates: Be sure to bookmark the Carelon MBM “coming soon” clinical guidelines and pathways page for easy reference

Did you know that Carelon MBM maintains a dedicated ‘Coming Soon’ page for our clients, providers and all portal users that highlights upcoming clinical guideline and pathway updates? 2025 guidelines updates are available now.

Summary of updates

• In late March, updates to our Radiology, Radiation Oncology, Rehabilitation and Genetic Testing solutions were implemented.
• Mid-June: The following updates will be implemented:
  • Chromosomal Microarray Analysis 2025-06-15
  • Interventional Pain Management 2025-06-15
  • Pharmacogenomic Testing 2025-06-15
  • Whole Exome Sequencing and Whole Genome Sequencing 2025-06-15

We recommend you and your practice bookmark this page for easy reference and refer to it whenever needed. You can also connect to our primary clinical guidelines and pathways site from MBM provider portal and our provider microsites.

Reminder: Our 2024 annual provider satisfaction survey is under way – make sure to participate before time runs out! Survey Closes November 27^th

Each year, Carelon Medical Benefits Management (MBM) distributes our annual provider satisfaction surveys to our provider portal users, laboratories and other third-party entities that request cases for our various programs including MBM specialty and post-acute programs. The survey lets us know how we’re doing, and more importantly, how we can do better.

Earlier this month, our vendor partner, Press Ganey, distributed the survey via email. We request that you help us to help you by completing it and providing feedback via our questions and in the free text response areas by November 8th.

Please note: The survey will close after this date. In addition to providing us with incredibly useful information, you will also be eligible to win a $150 Amazon eGift card!

Many of our projects, which are geared toward improving our programs, provider portal and even the call center operations, come from these survey results. Our clients, the health plans, are also interested in the results, as their goal is to enhance the provider and member experiences ongoing.

Don’t delay! Make sure to participate in the annual Carelon provider satisfaction survey.

Carelon to introduce post-call phone surveys for providers / portal users

In an effort to serve you better and learn how we can make your future call experiences with us as helpful and efficient as possible, we will be introducing a post-call survey providers and other portal users can share feedback with us on. This survey feature will be introduced later this year during the 4^th quarter.

Planned survey questions include:

• Based on this call, how likely is it that you would recommend Carelon to a friend or colleague?
• Based on your call, how much do you agree or disagree that Carelon is easy to do business with?
• What was the main reason for your call?
• Was your question or issue resolved in this call?
• Did you need to contact us more than once to resolve this issue?
• Overall, how satisfied were you with this call?

Carelon post-acute providers: Do we have your current provider information on file and verified? Be sure to check periodically and let us know of any changes needed!*

Help us to help you! To ensure we have your current contact and provider information on file, please notify us of any recent changes made or if you have upcoming changes, we’re happy to apply any changes needed in advance of their effective date.

If you are an existing Carelon Home Health, SDoH or Wound Care participating provider and need to update any of your provider information (i.e., NPI, email / mailing address or phone), please submit the provider change form available here.

For applicable providers, provider change request forms can also be accessed on our post-acute provider site. The link can be located under each of our specialty pages.

Reminder: Have you confirmed your phone and fax numbers with us?

Carelon is committed to protecting member’s Protected Health Information (PHI). To prevent disclosure of PHI to unauthorized recipients, Carelon requires confirmation of your phone and fax number. Carelon must receive this completed form prior to faxing authorization notifications. Thank you for your assistance in protecting member’s PHI. For multiple sites please submit a request for each location.

• Home Health, SDoH and Wound Care providers can access the online form to confirm their fax numbers for authorization requests here.
• PAC-IM providers can access the online form to confirm their fax numbers for authorization requests here.
• DMEPOS providers can access the online form to confirm their fax numbers for authorization requests here.
• All online fax confirmation forms can also be accessed on our post-acute provider site. The link can be located under each of our specialty pages.

We encourage all providers / portal users to check to ensure we have your correct fax on file with us – bi-annually if needed or at least annually. If there are any changes to your demographics (i.e., change of ownership, NPI change, tax ID change, and/or address change), please submit them at the time of the update.

Thanks for your partnership!

Use the MBM provider portal to help protect patient PHI and reduce usage of 1^st class mail

Carelon MBM has seen a recent influx of 1^st class mail for case submission supporting documents.  Although this is an accepted method for providers to supply additional information regarding prior authorization requests, it is not the preferred method, nor the most efficient.

Carelon MBM understands that most 1^st class mail is for Appeals, providing additional clinical information regarding prior authorization requests or is PCCA / claim-related.

We want to remind you that the easiest and most efficient way to get this information to us is via our MBM provider portal, which will reduce response time and help to connect your information to the correct prior authorization request sooner.

By using the Carelon MMB provider portal for your prior authorization requests – your appeal, additional clinical and/or PCCA, it will help your practice:

• Reduce turnaround time
• Reduce spend on mailing costs
• Help minimize handling of patient PHI (Personal Health Information) & PII (Personally identifiable information)
• Remove multiple inter department hand-offs
• Increase usage of MBM provider portal, which includes ongoing enhancements and a secure environment

If you have questions or concerns, please go to either the Provider Portal or call 800.252.2021 (Provider Portal Customer Support).

Help us to protect patient PHI and reduce errors by selecting the correct member

Follow these steps to help ensure correct member selection:

• Cross-check the member ID with member ID card before proceeding with the request. If verifying member ID via eligibility database, ensure you confirm member address.
• Verify and confirm the patient’s full name along with their date of birth.
• Verify the coverage plan associated with the right patient.

When submitting a case on the provider portal, be sure to select and confirm the correct office demographic information for both the ordering provider (office address & fax number) and servicing provider (office address). This is crucial as correspondence containing patient PHI is sent based on this information.

If you have questions or concerns, please go to either the Provider Portal or call 800.252.2021 (provider portal customer support).

Check this section of Provider Connections regularly for other tips and important reminders on how we can partner to help ensure protection of patient PHI.

Reminder: Help us to protect patient PHI: Be sure to use a new cover sheet for all fax submissions you submit to Carelon MBM

Earlier this year, we improved the monitoring capabilities in our fax handling process, including the ability to analyze incoming faxes more quickly and to address any issues we see on our end in an expedited manner.

We have found that some faxes being submitted to us include outdated and/or re-purposed cover sheets containing protected health information (PHI) for a member other than one in the body of the fax and wanted to bring this to your attention.

Please review your internal process and be sure a new and independent cover sheet is being submitted per each patient.

We will continue to separate fax sheets received on our end when we receive one for two separate members, but taking a simple inventory review step will help ensure each case is processed as quickly and efficiently as possible. It will also help ensure protection of patient PHI.

New year, new opportunity: Benefits of joining the Carelon MBM User Experience Feedback group

When you join our Carelon MBM User Experience Feedback group, you’ll have the unique opportunity to help shape our provider portal products and features and help influence where potential improvements can be made. We will reach out to you with these opportunities monthly.

This group of our users provide regular feedback for new designs and features in development and share their experiences to help improve the Carelon provider portal and the pre-authorization process.

Key benefits include:

• The opportunity to provide feedback – Take part in 5-10 minute surveys and quick online activities
• The option to partner with us and participate in online usability sessions, usually around 45-60 minutes.
• Optimized communication and training – Help us to learn about your unique work and processes. Have focused conversations lasting 15-60 minutes.

Don’t delay. Join us today!

• Complete our quick surveyand we’ll contact you with additional information to get you started in our Feedback group!
• Already a member? Be sure to encourage your peer providers to join today!

Getting to know the Carelon MBM Knowledge Services team

All guideline development work performed at Carelon Medical Benefits Management (MBM) begins with the Knowledge Services team. This team of graduate level professionals includes a methodologist and a group of experienced medical librarians who manage the research and evidence review process.

In partnership with the solution medical directors, the librarians develop research parameters for each cycle of guideline updates and conduct literature searches using processes that ensure the quality of the evidence supporting Carelon MBM’s guidelines. Relevant articles are graded according to a well-defined set of methodologies and reviewed by clinicians trained in evidence review.

The resulting body of evidence is used to inform development of new guidelines and updates to existing guidelines. The research librarians also conduct surveillance of emerging literature to ensure that any new evidence that potentially impacts Carelon MBM’s guidelines is brought to the attention of clinical leadership. Rounding out the team are two senior medical writers who draft documents prior to panel review and do all the heavy lifting required to publish the final documents.

This group of talented professionals provides the foundation for Carelon MBM’s evidence-based guidelines. For more information on Carelon MBM’s research process and methodology, please visit:

https://www.careloninsights.com/medical-benefits-management/specialty-care

Aligning care with best practices: clinical appropriateness review

This is an amazing era for medicine. New tests, treatments, and medications hold the promise of improving or even saving lives.

But not all innovations create meaningful benefits, and not all care that is administered follows accepted standards for care. The costs associated with care that is not appropriate create a burden on our entire health system and can leave patients without the means to pay.

In the complex arena of health care, rapid advances in medicine make it hard for physicians to keep up with the latest evidence-based guidelines and variation from established best practices compromises efficiency, effectiveness, quality, and safety in care.

Carelon Medical Benefits Management (MBM) helps ensure clinically appropriate care is adopted across today’s most complex, costly, and specialized clinical areas. Our clinical guidelines and pathways, supported by our cloud-based technology, are the foundation of our clinical appropriateness review process.

Setting the standard for clinical guidelines

Development of our clinical guidelines and cancer treatment pathways is led by Carelon MBM medical directors, physicians highly qualified in their fields, engaged in a rigorous process of evidence-based literature review.

After reviewing the published literature, our medical directors consult with some of the country’s leading physician experts and independent subject matter experts. Our guidelines are then reviewed by an independent panel.

These guidelines are updated at least once annually, and more often when significant new evidence is published.

We participate in the development of appropriate use criteria for the Centers for Medicare & Medicaid Services (CMS) Appropriate Use Criteria Program, an advanced imaging clinical decision support mandate for Medicare fee-for-service beneficiaries. To develop the criteria, we are collaborating with the Rayus Quality Institute, a nonprofit affiliate of Rayus Radiology and a CMS-designated provider-led entity.

Clinical rigor

Carelon MBM performs three levels of clinical guideline development and governance:

1. Subject matter experts: building a reservoir of available research
   To assemble and build on the available evidence-based-care research, we engage practicing, board-certified physicians who possess clinical expertise in the respective guidelines’ domain, such as sleep medicine and radiology. These physicians serve as subject matter experts (SMEs) and contribute in several ways. For example, they couple their expertise as practicing physicians with analysis of primary literature, specialty society guidelines, and technology assessments.
2. Specialty review panels: supporting guideline development
   The formal governance of guideline development begins with specialty review panels. Chaired by one of our solution medical directors, each panel includes at least three board-certified physicians with expertise in relevant specialties. We select the panelists based on their proficiency in their clinical specialty or in healthcare research. Like our SMEs, our panelists perform numerous tasks: they assist with drafting guidelines, offer counsel on guidelines, and provide recommendations to the independent multispecialty physician panel.
3. Independent multispecialty physician panel: reviewing and approving guidelines
   The independent multispecialty physician panel is an autonomous group that has final decision-making authority for approving guidelines. The panel consists of at least seven board-certified practicing physicians and represents various regions, specialties, and practice settings. This multidisciplinary approach balances the input integrated in the development process, especially regarding primary care, specialist, and subspecialist referral patterns and patient considerations.
4. Clinical innovation: why our work is never done
   Medicine advances at a fast pace. Our team is actively engaged in reviewing, discussing, and analyzing medical advancements, breaking news, and recent technologies. Moreover, we constantly examine our processes and tools to find ways to create new value for health plans, their members, and their providers.

Our approach to innovation:

• Advancing our clinical solutions to focus on areas of rapid change and escalating costs, such as genetic testing, specialty drugs, and musculoskeletal and pain management
• Developing new partnerships that drive more value for health plans and improve clinical decision support for providers
• Automating the review process with a flexible, new platform that enables greater precision and an optimized review. A highly trained team supports the platform, which features an intuitive portal that empowers better clinical decisions and inspires behavior change
• Focusing on the most prevalent conditions affecting the US population, such as headache and lower back pain, and updating our processes to achieve impact where it is most needed
• Mining big data to uncover trends and practice patterns that can inform network management initiatives and benchmarks. By serving a large, national client base, we have developed a comprehensive source of provider behavior, generating insights into true practice patterns across the US and regionally.

For your convenience, you may access Carelon MBM clinical appropriateness guidelines and cancer treatment pathways here.

Carelon Post Acute Solutions will begin operating as Carelon Medical Benefits Management on April 1, 2024

On April 1, 2024, Carelon Post Acute Solutions (formerly known as myNexus) will begin operating as Carelon Medical Benefits Management. While documents that use the Carelon Post Acute Solutions name today, such as determination letters and provider forms, will adopt the new name, there will be no changes in the way you submit a case or to the contact information you use for checking case status.

Please see below for a list of frequently asked questions (FAQs). Additional questions can be directed to our provider relations team using the contact information below:

Home Health Providers: HHprovider_relations@carelon.com

PAC-IM (Post-Acute Institutional Management) Providers: PACprovider_relations@carelon.com

DMEPOS Providers: DMEprovider_relations@carelon.com

Thank you for your continued partnership.

Frequently asked questions
1. Will there be any changes to the Carelon Post Acute Solutions provider portal?	1. The name of our portal will be updated to reflect Carelon Medical Benefits Management branding. Additionally, the web address (URL) you use today will automatically redirect to a new Carelon site. There will be no changes to the case submission process.
2. Are any phone number changes planned as part of this transition?	2. No. Our inbound phone numbers will not change. The reference to Carelon Post Acute Solutions in recorded scripting will use the Carelon Medical Benefits Management name.
3. How will third party portals, such as Availity, be impacted?	3. There will be no change to the way you access these portals. Within the portals, any reference to Carelon Post Acute Solutions will be replaced with the new name. This may take some time to fully complete.
4. Will references to Carelon Post Acute Solutions on health plan websites and other materials be changed?	4. Yes. While you may continue to see the Carelon Post Acute Solutions company name on health plan websites for some time, these references will be updated over time through scheduled content update cycles. If your office includes the Carelon Post Acute Solutions name in any materials or web properties, we encourage you to update them to Carelon Medical Benefits Management during your next update cycle.
5. Will information about Carelon Post Acute Solutions continue to be found on the corporate website?	5.  Yes. post-acute care remains a Carelon solution and will be part of the Carelon Medical Benefits Management portfolio of solutions. You can learn more at www.careloninsights.com
6. Will provider resources, such as key documents and the provider finder, be impacted?	6. Yes. Our provider resources will continue to be available through our corporate website, and our Provider Resources site. You can access the Provider Resources site here:   https://providers.carelonmedicalbenefitsmanagement.com/postacute/.
7. Does this impact provider agreements with Carelon PAS? Will I need to sign a new agreement?	7. No. There is no impact to provider agreements, and you do not need to sign a new agreement regardless of whether your current contract is with myNexus or Carelon Post Acute Solutions.
8. Do I need to complete credentialing again through Carelon MBM?	8. No. Providers will not need to re-credential until their normal credentialing cycle.
9. Will my claims be impacted?	9. No. Claims are not impacted. Payer IDs will remain the same.
10. Will I need to update my W-9?	10. Providers may need to update their W-9.  If you need an updated Carelon MBM W-9, please contact the Carelon Provider Relations department at HHprovider_relations@carelon.com