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.

Introducing our new genetic testing program clinical engine

The Carelon genetic testing program is proud to announce the launch of our new clinical engine. The development of this new clinical engine allows us the ability to not only deliver a number of key enhancements making the process more accurate and efficient, but also provides us an opportunity to better categorize data, offer more configurability, and provide the structure for more agility for future enhancements.

Along with the development of this new clinical engine, we have also expanded our team to include nearly fifty board-certified genetic counselors, making Carelon MBM one of the top centers of expertise in genetics throughout the nation.

This expansion allows not only a level of genetic testing review expertise unmatched in the market today, but also the best possible provider-centric service for our ordering physicians to discuss their questions surrounding genetic testing.

To learn more about the genetic testing program, please visit our provider site at https://providers.carelonmedicalbenefitsmanagement.com/genetictesting/.

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.

Scheduled peer-to-peer discussions now available for medical oncology

As of July 10, 2023, our medical oncology program offers scheduled peer-to-peer discussions for requests that do not meet medical necessity criteria. This will ensure a more efficient review of your request and decrease ordering physicians’ hold times to speak with a Carelon physician reviewer.

When a request cannot be approved immediately, the ordering physician or their clinical representative has the option to discuss the case with a Carelon medical oncologist. A peer-to-peer discussion is always offered before any adverse determination is made, but a peer-to-peer discussion can also take place after an adverse determination.

To schedule a peer-to-peer discussion, call the Carelon contact center and inform the representative you would like to schedule a medical oncology peer-to-peer discussion during Carelon business hours. Any individual that is a representative of the ordering physician may schedule a peer-to-peer on behalf of the physician.

Medical Oncology Program Enhancements 

This spring, Carelon began rolling out an advanced clinical engine for our Medical Oncology providers that will enhance the provider experience and enable future reporting opportunities.

The clinical engine enhancements, which will continue through the beginning of 2024, will result in a more user-friendly case intake process for portal users. Providers can submit requests via the provider portal while the changes are being made. However, you may notice that the clinical intake screens look and function differently.

A few of the enhancements we’re implementing 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

Learning resources

There are several ways you can learn about the updated authorization request process for Medical Oncology requests.

These include:

• Case entry tutorial video – A recorded demonstration of the case entry process is available in the Tutorials section under the provider portal Help Desk (requires portal log in).
• Provider training sessions – An overview of the case entry process will be covered and more. Providers can register on the Provider Connections blog training page or below.

• Contact us – If you have questions about our provider portal or the case entry process, you can connect with our Medical Oncology team at MedicalOncologySolution@carelon.com.

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.

New enhanced functionality:

Our Musculoskeletal Program now allows the date of service to be changed on our provider portal for approved prior authorizations. We recognize that surgical dates can change and wanted to make it easier for providers to make this update without having to call Carelon.

Tip #1: The top five critical ingredients we need you to send to help authorize your case are:

1. 1. Your physician’s note needs to describe the exact surgery being planned, and the reason the surgery is needed.
   2. The note needs to say when the patient started having pain/symptoms, the severity of the pain, and how the pain effects the patient’s activities.
   3. The note needs to include an assessment of the physician’s recent exam of the painful area.
   4. The note needs to tell us what type of treatment the physician prescribed, how long the patient tried the treatment, and if the treatment improved the patient’s pain/symptoms.
   5. A copy should be sent of the radiologist’s report of any recent x-ray, CT, MRI, or ultrasound ordered by the physician to diagnose the reason for the pain/symptoms.

If any of these are missing, we may not have enough information to authorize your case.

Note: For a procedure to be pre-authorized, the notes have to show that your patient has the symptoms, exam, treatment, and imaging that meet Carelon’s criteria for the surgical procedure you are requesting. You can view the criteria at: (put in link for Joint guidelines).

Tip #2: Did you know that some procedures must have a radiologist report for pre-authorization?

If your doctor ordered a CT scan or MRI to find out the reason your patient has pain/symptoms, you need to send us a copy of the radiologist’s report.

Some offices copy and paste the report’s “impression” into their Electronic Medical Record (EMR). The impression does not always include important information that is in the rest of the report.

To avoid delays with your authorization request, remember to submit the radiologist’s report.

Providers can check the microsite for 2023/2024 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.

Now live: OptiNet September enhancements implemented!

Carelon Medical Benefits Management (MBM) understands the key role that medical practices play in the delivery of care for patients who require imaging studies. Developed in collaboration with your health plan, our radiology program helps support care that is consistent with current medical evidence and delivered in the most clinically appropriate setting.

As you know, OptiNet helps with site servicing selection! When we are contacted to order imaging studies, we offer the information we collected in OptiNet to help locate clinically appropriate, convenient, and cost-effective alternate imaging study facilities for patients, so please be sure to always keep your registration complete and current.

What is OptiNet?

OptiNet is an online assessment tool designed to collect service and capability information. It is a self-reporting tool for servicing providers to report information offered at their imaging and genetic testing locations and to assist with ordering providers search results during site selection for pre-authorization orders. The information collected helps to support the Carelon MBM site of care program, Specialty Care Shopper OptiNet initial display, and imaging credentialing programs.

Why we are reaching out?

Our records indicate you currently are registered in OptiNet. We have made some changes to the application that we would like to keep you informed about.

What changed?

Effective September 9, 2023, OptiNet is no longer a pop-up window! When clicking on “Access Your OptiNet Registration” you will be transitioned into OptiNet seamlessly.

Once in OptiNet, and you are within a record or registration, you can easily “Return to Search Results”, this hyperlink has been added to the top of the page and will bring you back to your original search.

If you need to go back to the portal application, or to transition between RBM and GT OptiNet, the OptiNet “Home” hyperlink at the top of the page will allow you to do just that.

What’s next?

• Be on the lookout for even further enhancements within OptiNet!
• For our October enhancements check out our Helpful Guide section for additional OptiNet documentation.
• Any changes we make within our OptiNet application is to make it more user-friendly! We hope these changes help you navigate within the application easier.

If you have any questions, please do not hesitate to contact our OptiNet assessment team at: (877) 202-6543 or at Assessment@carelon.com.

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.

Rehabilitation program updates: What’s new at Carelon Medical Benefits Management?

We have implemented some enhancements to our Carelon MBM Rehabilitation program that we’re excited to share with you!

We recently updated the Rehabilitation provider search functionality within therapy requests. Previously, users were asked to name the billing entity, and if applicable, were also asked to enter the treating therapist for the request. Following the update, users are only being asked to enter the provider who is selected as the billing entity for the request.

The Rehabilitation program recently completed a clean-up of therapy requests that had been initiated by a portal user, but not submitted. Carelon canceled out any incomplete requests that were open for more than seven days.

If the user pulls up one of the canceled requests, they will get a message letting them know it was canceled due to being open for more than seven days, “This request was canceled due to being open more than seven days. If the service is still needed, please start a new request.” If skilled services are still required, the user will need to submit a new request.

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.

Upcoming change to order ID’s – surgical program

We’ve made a recent change to our surgical program. Order ID’s for Carelon’s surgical program are distinguishable by the letters “SU” preceding a 9-digit number. However, the numerical portion is all that’s necessary to find an order.

Beginning July 15, 2023, you only need to enter the 9-digit number when you “check order status”.

Examples: