Tips and tricks

Visit the Cardiology provider microsite to access helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more.

Visit the Genetic Testing provider microsite to access helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more.

Harvard Pilgrim providers: Please visit the Harvard Pilgrim Genetic Testing provider microsite.

Our provider microsites provide access to helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more. Contact your health plan representative for the program link applicable for their Carelon Medical Oncology program.

Provider portal case entry enhancements 

Beginning in March and continuing through June 2023, Carelon Medical Benefits Management released operational enhancements to the provider portal for the medical oncology program. These enhancements were geared towards creating an easier intake process for users. Providers can submit requests via the provider portal while these changes are being made, however you may notice the clinical intake screens look and function differently.

A few of the changes include:

• • • Improved look and feel of the case entry screens
    • Removal of unnecessary biomarker questions for specific cancer types
    • Available Pathway regimens will be shown earlier in the request process
    • Revised drug dosing screens for inputting cycle ranges and days of administration

Resources, training and support

To familiarize yourself with the enhancements to the medical oncology authorization request process, the following resources are available for providers.

Timeline for Enhancements 

Since early March, Carelon has been applying medical oncology system updates in a staggered approach by individual health plan. You may notice during this time of transition that one health plan may see the old request screens, and another will use the new request process. This will be temporary until all health plans are transitioned by June 2023, as outlined below.

Need additional information?  

Carelon has a designated email address for provider questions about the provider portal and case entry process. All member eligibility or claims questions should be directed to your health plan network representative. Thank you for your continued support of this program.

What are Carelon Cancer Treatment Pathways?

Our medical oncology program highlights evidence-based, cost-effective care and guides physicians to optimal Pathways that drive the best outcomes for members. The Carelon Cancer Treatment Pathways is a clinical resource designed to help providers choose the most appropriate treatments for health plan members with complex clinical needs, though the final treatment plan is made between the provider and the member.

Carelon Cancer Treatment Pathways are developed using a rigorous review of professional consensus guidelines and published clinical data. When evaluating a regimen’s clinical merits, Carelon oncologists consider:

• • Clinical benefits (efficacy)
  • Side effects/toxicity – particularly side effects impacting quality of life or commonly leading to hospitalizations
  • Strength of consensus guidelines

Lastly, those regimens that have favorable efficacy and toxicity profiles as compared to all other chemotherapy treatments for the same diagnosis are evaluated based on cost.

We recognize that every patient is unique. While efforts have been made to identify pathways that offer the best treatment options for most patients, a treating oncologist may decide that another regimen is best for an individual patient, select a non-pathway regimen, and still have that regimen approved under medical policy.

For more information on which regimens and applicable clinical details are needed to be considered on Pathway, review the Carelon Cancer Treatment Pathways & Guidelines – Carelon Medical Benefits Management.

Requesting drugs with oncological and non-oncological uses

Our medical reviewer teams frequently receive questions on drugs used for both oncological and non-oncological indications. To help ensure you and your peers know who to contact for authorization, we’ve assembled a guide for commonly requested drugs and possible diagnoses.

As a reminder, the Carelon Medical Oncology Program will only accept requests for drugs with a primary cancer diagnosis. For patients with a non-cancer primary diagnosis, check with the member’s health plan to verify if another entity needs to authorize the requested drug.

Below are examples of how a primary and/or secondary diagnosis may be presented for drugs used to treat side effects related to cancer treatment.

• • Primary= the cancer has caused/contributed to a secondary diagnosis being treated by the requested agent
  • Secondary= the diagnosis being treated by the requested agent

If the primary diagnosis is cancer and the drug is being used to treat side effects related to cancer treatment, then the request can be submitted to Carelon. However, Carelon does not support or include reviews of secondary diagnoses. Please check with your ordering provider about the primary diagnosis prior to submitting a request with a specific entity.

Visit the Musculoskeletal provider microsite to access helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more.

What’s new in the Musculoskeletal Program?

Our dedicated Musculoskeletal Program team has prepared some helpful tips and updates for you and your team members.

• • Tip #1: The Musculoskeletal Program microsite is a valuable source of information that provides details on the Carelon Musculoskeletal Program. The Resources section on the microsite includes downloadable “order request checklists”, which will tell you what information you’ll need enter your request.
  • Tip #2: For cases that require documents to be uploaded, a list of documents will be made available that are required to complete the review of the case. For best results, upload documentation prior to submitting the order request.

Effective September 11, 2022, a Carelon clinical guideline update was applied for the Musculoskeletal Program. If you would like to view the updated guidelines, please visit our Musculoskeletal Program clinical guidelines page.

Providers can check the microsite for 2023 quarterly session dates and sign-up for a future training session on our Musculoskeletal Program microsite.

Visit the Radiation Oncology provider microsite to access helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more.

Viewing radiation therapy CPT codes

For our radiation oncology/therapy program, the list of managed CPT codes can vary by health plan or by line of business (commercial, Medicare, Medicaid). Providers can view the list of included CPT codes and the corresponding category (modality) by using the look-up feature in the provider portal. As a reminder, providers need to request a specific modality (brachytherapy, IMRT, etc.,) and cannot select individual codes. However, if a code is not on the CPT code list, this means AIM is not managing the code and the provider should contact the health plan for more details.

How to access the CPT code list

1. 1. 1. Log in to the provider portal and click the “Help Desk icon from the home page.
      2. Select “Radiation Therapy Code Lookup”.
      3. Within the view CPT Codes, select the “health plan” name, and “year”.
      4. Click “Find”.
      5. Use the column headers to sort the list by code, description, or category to view the CPT codes included in the radiation therapy program for that health plan.

Utilize the radiation oncology order request worksheets

The Radiation Oncology Program has comprehensive order request checklists to help providers identify and collect the information in advance to have it available when entering requests using the Carelon provider portal. We recommend printing a copy or saving it to your computer to keep it handy when you’re preparing to submit an order.

The order request checklists and other helpful information can be found under the Resources section of the microsite.

Visit the Radiology provider microsite to access helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more.

Don’t wait. Register your imaging site of care with OptiNet® today!

Carelon understands the key role that medical practices play in the delivery of care for patients who require imaging studies. Developed in collaboration with health plans, our Radiology Program helps support quality care that is consistent with current medical evidence and delivered in the most clinically appropriate setting.

Our program includes OptiNet, which is available in the provider portal. OptiNet is a proprietary, multifaceted program designed to collect service and capability information on outpatient imaging providers.

About OptiNet

Available to our health plan clients, OptiNet is the Carelon assessment tool that gives providers more transparency when ordering high-tech imaging procedures and more. OptiNet generates a modality score based on equipment, staffing, and quality control information reported by the facility.

It is available in the provider portal.

Register your imaging facility today!

Choosing an imaging provider is an important decision for our customers, affecting the quality and cost of their care. The Carelon OptiNet tool will help providers and their patients compare high value, lower cost imaging facilities for computed tomography (CT) imaging, magnetic resonance (MRI) imaging, and other imaging services.

Why is registration important?

When you register, your facility information is displayed in the provider portal. By registering, your facility may be available on our Initial Display List to ordering physicians and members requesting imaging services. Providers register sites within OptiNet to become eligible alternate sites for our Site of Care and Carelon Specialty Care Shopper (member engagement) programs.

What do you need to do?

Register in the OptiNet tool.

How to register

1. Log in to the provider portal at https://providerportal.com.
2. Select “Access Your OptiNetRegistration” found on the left-hand side of the provider portal home page.
3. OptiNet will guide you through the registration process.

What data will be included?

The Carelon online registration tool, OptiNet, collects data on imaging providers related to: facility specifications, technologist and physician qualifications, accreditation, equipment features, and technical registration. This information is used to determine how organizations conform to industry-recognized standards, including those established by the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC).

For more Information:

View our provider microsite to learn about the many benefits of OptiNet.

If you have any questions about the OptiNet registration or score card generation, please contact the Carelon Assessment Department at 877.202.6543 or by email at Assessment@aimspecialtyhealth.com.

Visit the Rehabilitation provider microsite to access helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more.

Rehabilitation program tips

Rehabilitation providers: For easy reference, here is a summary of recent information added to our FAQs posted on the rehabilitation microsite.

How often should providers update the episode of care initial evaluation date in the Carelon portal for members receiving long-term therapy services?

Within the Carelon rehabilitation program, requests are staged based on the initial evaluation date of service as well as the previous request for medical necessity determination. For these reasons, providers are asked to keep the initial evaluation date consistent throughout the member’s episode of care when submitting prior authorization requests for additional treatment.

There is one scenario in which the initial evaluation date may change and that is typically for chronic, long term or pediatric episodes of care that extend past a calendar year of treatment. In these scenarios, there is a reasonable expectation that the initial evaluation and plan of care would be updated annually. The updated initial evaluation date should also be documented annually within in the member’s therapy treatment requests on the Carelon portal.

What should a provider do if they have not received the request determination, but the patient is scheduled to return for treatment soon?

If a provider has not received a determination on their request and the patient is returning to the facility, the provider may contact the Carelon Call Center and ask that the request be reviewed live. If the provider is unable to hold while the request is reviewed, the provider facility can request a call back once the review is completed.

What are the most common reasons a second treatment prior authorization request receives a lower visit allocation (i.e., 2-4 visits)?

When a second treatment request received a lower than typical visit allocation, there are a few possible reasons for this outcome.

• • • Did the provider document an in-scope functional outcome tool (from the microsite list) on the initial treatment request and document a baseline score?
    • Did the provider reference the scoring scale on the provider microsite to ensure that the functional outcome tool score documented matched the scoring scale that Carelon utilizes?
    • Did the provider document an in-scope functional outcome tool (from the microsite list) on the second treatment request and document an updated score from the member’s most recent visit?
    • Did the provider document a mitigating factor in the event of little to no progression documented on the functional outcome tool score between the initial or second treatment requests?
    • Did the provider document a change to the plan of care in the event of little to no progression documented on the functional outcome tool score between the initial or second treatment requests?
    • Did the provider document short-term goal achievement on the second treatment request?
    • Has a benefit limit been reached, where benefit limits apply?
    • Has the member achieved the plan of care functional goals when two visits may be appropriate for discharge planning and home exercise program instruction?

The provider has the option to call Carelon at any time for a peer-to-peer discussion if they feel the details of their request need to be clarified.

To access our full set of rehabilitation program FAQs, visit the Getting the answers you need section of our provider microsite.

Visit the Sleep provider microsite to access helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more.

Sleep durable medical equipment (DME) – How we manage PAP compliance

Carelon Medical Benefits Management (Carelon) is continually looking for ways to enhance the provider experience by ensuring an efficient order request entry and adjudication process.

With that in mind, Carelon’s sleep solution offers management of obstructive sleep apnea from diagnosis to treatment options. If the best treatment is determined to be the use of a positive airway pressure machine (PAP), then Carelon monitors member compliance of device usage through an automated process that saves durable medical equipment (DME) providers time when requesting future authorizations.

As a reminder, the DME provider needs to select Carelon Medical Benefits Management (AIM Specialty Health) on the manufacturer’s site to match the member to Carelon. This could be listed as different fields on each manufacturer’s site. For Phillips devices, Carelon is listed under ‘external services’ on the manufacturer’s site and for ResMed, Carelon (AIM Specialty Health) is listed under ‘add integrator details.’

When a member is diagnosed with obstructive sleep apnea and requires treatment with a PAP (positive airway pressure) device, the request is reviewed for medical necessity by Carelon. The request is authorized if it meets medical necessity review. The DME provider then registers the device to the member within the manufacturer’s website, using member demographic data and instructs the manufacturer site to match the member data to Carelon (AIM Specialty Health), which validates the member data within Carelon’s system.

This allows Carelon’s system to receive member and manufacturer data from the manufacturer’s site. Carelon then utilizes this information when a subsequent request is entered for ongoing PAP supplies and pre-populates member device usage data within the request, which saves providers time and makes entry of the order request more efficient.

For more information on the sleep program, including how to enter an order request, please visit the provider microsite.

Reminder: Sleep program equipment recall notice still in effect – March 2023

On June 14, 2021, Philips Respironics issued a voluntary recall on specific brands of their CPAP/APAP, BiPAP machines. Philips has established a registration process that allows patients, users, or caregivers to look up their device’s serial number and initiate a claim if their unit is affected.

To view the recall information and register your device, use the following link: https://www.usa.philips.com/healthcare/e/sleep/communications/src-update

We will keep you informed of future updates related to this recall on our provider microsite.

Visit the Surgical Procedures provider microsite to access helpful information and tools such as a direct link to the provider portal, clinical guidelines, FAQs and more.