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.

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 Medical Benefits Management provider portal branding change

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.

How does Carelon use the annual provider satisfaction survey results?

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:

• The Reference Desk is now the Carelon Help Center – easier navigation, more comprehensive tutorials
• Training is now posted in the Carelon provider portal and in our microsites
• Microsites are posted in the Carelon provider portal
• Webinars with Q&A sessions are part of our training
• Increased the number of characters allowed in the Additional Clinical Information text box for cases that do not approve right at case submission on the portal

These are some coming features that our survey responses influenced:

• Letter availability within the provider portal
• Find orders module which allows users to search for orders across programs via order number or member
• Improved communication when there are any Carelon service disruptions

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!

Our first days as Carelon Medical Benefits Management

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.

Reminders:

• This was a name change only and it did not impact the services Carelon offers or the way we work with providers.
• No changes have been made to the way you submit a case or the contact information you use for checking case status.
• Our provider portal address did not change; all providers continue to have access to providerportal.com, unless required by the health plan to go through the single sign on. Navigating to it from our corporate website is also easy via our new URL: www.careloninsights.com/sign-in-or-register.
• Our corporate website address did The new URL is www.carelon.com, which we encourage you to bookmark for easy reference, along with www.carelon.com/capabilities/medical-benefits-management.
• Our former site link has been redirected to our new URL.
• Our corporate clinical appropriateness guidelines and cancer treatment pathways website address has changed. The new URL is carelonmedicalbenefitsmanagement.com. Our former site link has been redirected to our new URL.
• Our provider microsites did You can locate the new links in the Tips and tricks section of this blog. The former site links have been redirected to the new URLs.
• No changes have been made to the way you access third party portals, such as Availity.
• No inbound phone numbers have been changed. All references to our company name in recorded scripting have been updated to Carelon.

If you have any questions, please connect as needed: WebCustomerService@carelon.com. Please see below for a list of frequently asked questions (FAQs).

Provider brand transition FAQs

Have you visited our new Carelon Medical Benefits Management corporate website yet?

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:

• Carelon MBM provider portal
• Carelon MBM clinical appropriateness guidelines and pathways
• Our provider resources access page

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:

• Carelon PAS provider portal
• Carelon PAS provider materials website

Employee spotlight – Meet Stefanie

Senior UX Researcher and Designer

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.

“I love learning user behaviors and perceptions in our applications through research. There’s a lot of practice and joy in listening and talking with people. I use research methods that include in-person observations, surveys, and remote feedback sessions. I guess you could say I’m an explorer at home and at work.”

Stefanie can often be quoted saying “No matter what happens, something good is about to happen. No matter what.”