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.
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.
Carelon MBM performs three levels of clinical guideline development and governance:
Our approach to innovation:
For your convenience, you may access Carelon MBM clinical appropriateness guidelines and cancer treatment pathways here.
Earlier this year, we introduced our new company name, Carelon Medical Benefits Management (MBM). Carelon is our multi-faceted healthcare services brand dedicated to solving the industry’s most complex challenges.
As a follow up to this rebranding, you may soon notice that our former ProviderPortal name will soon be shown as Carelon MBM provider portal or in some instances, simply provider portal. This is a name appearance change only and does not impact any functional changes to the portal.
Annually, Carelon sends out its provider satisfaction survey in the late fall to determine what we can do to improve your experience with our call center and the Carelon provider portal. Your feedback is extremely important to us, and we use it to make modifications to our approach when making improvements to the provider portal.
Here are some of the improvements Carelon has implemented based on what you, the provider, have told us:
These are some coming features that our survey responses influenced:
Carelon would like to thank those who completed our annual survey this year; you can see how many updates (improvements) we have already made based on your responses. We will be prioritizing initiatives throughout the year, based on your feedback, and continue to improve your Carelon experience.
The survey is not the only way to tell us what you want. We have a dedicated email address that is available all year for your suggestions: .
We look forward to hearing from you!
Effective March 1, 2023, we introduced our new company name, Carelon Medical Benefits Management. Carelon is a new healthcare services brand dedicated to solving the industry’s most complex challenges, with the benefit of no changes to the effective services and staff you’ve come to rely on.
If you have any questions, please connect as needed: WebCustomerService@carelon.com. Please see below for a list of frequently asked questions (FAQs).
|1. Will the AIM ProviderPortal URL or platform name be changed?||1. Our portal address will not be impacted; all providers will continue to have access to www.providerportal.com, unless required by the health plan to go through the single sign on. The AIM logo will be replaced with a Carelon logo. No changes are being made to our case submission process.|
|2. Will there be any changes to the AIM Clinical Guidelines URL or content?||2. The web address (URL) you use today will continue working, but will be automatically redirected to a new Carelon URL. The branding will be updated to reflect the Carelon branding.|
|3. Are any phone number changes planned as part of this transition?||3. No inbound phone numbers are being changed. The reference to AIM within recorded scripting will be replaced with Carelon Medical Benefits Management.|
|4. How will third party portals, such as Availity, be impacted?||4. There will be no change to the way you access these portals. Within the portals, any reference to AIM Specialty Health will be replaced with the new name. This may take some time to fully complete.|
|5. Will references to AIM on health plan websites and other materials be changed?||5. Yes. While you may continue to see the AIM company name on health plan websites and member ID cards for some time, it’s expected that these will be changed through scheduled content update cycles.|
|6. Will the AIM corporate website URL be changed?||6. Yes. The corporate website will be moved to www.carelon.com
All links to ProviderPortal and our clinical guideline pages will remain active and will be redirected.
|7. Will the provider microsite URLs be changed?||7. Yes. The provider microsite URLs will be automatically redirected to new Carelon URLs, and the branding will be updated to reflect the Carelon branding. Please bookmark the new URLs after you are redirected.|
This past March, we introduced our new company name, Carelon Medical Benefits Management. Carelon is our new healthcare services brand dedicated to solving the industry’s most complex challenges, with the benefit of no changes to the effective services and staff you’ve come to rely on.
Be sure to bookmark our new website for continued easy access to our provider portal and tools, new program information, important program enhancements, training opportunity news, access to our Provider Connections news blog and more: https://www.careloninsights.com/medical-benefits-management/specialty-care
There is a convenient Providers drop down menu in the navigation bar that provides quick access to such tools as:
About Carelon Post Acute Solutions
Through our post acute care programs, we ensure patients receive quality, seamless care when and where they need it most, such as the home or a post-acute care facility.
We do this by working with providers like you or our own local network to align care with the latest evidence and health plan care management plans.
If you service post acute solutions members, you’ll also find convenient access from our Providers drop down menu to:
Stefanie has been a researcher with Carelon for six years. Previously, she worked with Northwestern Memorial Hospital as a CT technologist and has always been an artist. As a UX researcher and designer, Stefanie works with customers and end users to better understand their unique concerns so Carelon can deliver the best user experience possible.
“After we wrap up a research study with participants, a big part of my job is making recommendations for potential improvements of our programs and portal. It excites me to know that our participants, through objective feedback, take part in future enhancements to our products. The User Experience team gold standard is to learn more about the people using our systems and what motivates them. This is why we take the time to see what leads the user through their journey and really listen to what they are telling us.”
When Stefanie is not working, Stefanie enjoys laughing with friends and family, creating art, visiting different cities, being in nature, and streaming sci-fi, British drama & suspense.
Stefanie can often be quoted saying “No matter what happens, something good is about to happen. No matter what.”
By joining 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.
Members of this group will work with the Carelon User Experience team to:
Your feedback will help identify opportunities for improvements and enhancements, such as development of our new portal Help Center. Recent feedback has resulted in enhancements and updates to our Help Center and Tutorial sections. We will reach out to you with these opportunities monthly, depending on the types of services you may request pre-authorizations for.
Complete our quick survey and 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!