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.

Our annual provider satisfaction survey results are in!

Thank you to everyone who participated in our recent provider satisfaction survey. Results and future provider experience improvements will be shared in the upcoming months.

Each year, Carelon Medical Benefits Management (MBM) distributes our annual provider satisfaction survey to our provider portal users, laboratories and other third-party entities that request cases for our various programs including, Medical and Radiation Oncology, Genetic Testing, Rehabilitation, Musculoskeletal, Surgical, Radiology, Cardiology and Sleep programs. The survey lets us know how we’re doing, and more importantly, how we improve the provider experience.

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 improve both the provider and member experience.

Watch for information and dates on participating in this our next survey to come later this year.

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We have found that some faxes being submitted to us include outdated and/or re-purposed cover sheets containing protected health information (PHI) for a member other than one in the body of the fax and wanted to bring this to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!
Be sure to bookmark the Carelon MBM “coming soon” clinical guidelines and pathways page

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?

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.

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:


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


Do you want to help shape the provider experience for you and your colleagues? Join our Carelon MBM User Experience Feedback group today!

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:

  • Provide feedback – Take part in 5-10 minute surveys and quick online activities
  • Partner with us– Participate in online usability sessions usually around 45-60 minutes
  • Helps us learn about your work – Have focused conversations lasting 15-60 minutes

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.

Are you interested in providing your feedback?

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!


How to contact Carelon

The web customer service phone number for provider portal is 1.800. 252.2021. It is located below the log-in page of the provider portal, should you need to locate it quickly. This number may be used to troubleshoot or report portal issues, get all your users the ability to view each other’s orders, or learn how to use certain functionality within the portal.