Carelon Medical Benefits Management understands the key role that medical practices play in the delivery of care for patients who require imaging studies. Developed in collaboration with your patients’ health plans, our Radiology program helps support quality care that is consistent with current medical evidence and delivered in the most clinically appropriate setting. And that’s good news for your practice and your patients.
Our Radiology review process
Carelon is here to assist in your efforts to deliver the best quality and affordable care for your patients. The clinical information you submit is reviewed against Carelon clinical guidelines and health plan specific medical policies to ensure alignment with current best practices. Providers benefit by having a central location to obtain authorizations required by your patients’ health plans.
Contact Carelon to obtain pre-service review for the following non-emergency services:
- Nuclear imaging, including myocardial perfusion imaging, cardiac blood pool imaging, infarct imaging and Positron Emission Tomography (PET) myocardial imaging
- Computed Tomography (CT), including CT angiography, derived fractional flow reserve, structural CT and quantitative evaluation of coronary calcification
- Magnetic Resonance Imaging (MRI)
- Magnetic Resonance Angiography (MRA)
- Magnetic Resonance Spectroscopy (MRS)
- Functional MRI (fMRI)
- Stress Echocardiography (SE)*
- Resting Echocardiography (TTE)*
- Transesophageal Echocardiography (TEE)*
* Echocardiography may also be included in the scope of the Cardiology Solution
Our Site of Care review process
Our review process encompasses:
Imaging Study Review
Using the patient’s clinical information that you submit, we conduct a clinical appropriateness review of your advanced imaging request against our evidence-based clinical guidelines or your patient’s health plan medical policy.
Imaging Clinical Site of Care* Review
Imaging Clinical Site of Care is an expanded program in which we review clinical criteria to determine if an imaging service requires a hospital-based outpatient setting, which offers a higher intensity of service resources, or if a free-standing imaging center is a clinically appropriate and available alternative.
There may be circumstances in which a patient’s clinical situation requires that he or she receive an MRI or CT scan in a hospital facility. Based on the information you provide, we will review both the requested advanced imaging scan for clinical appropriateness and the site of care against health plan clinical criteria.
We will also identify alternate free-standing imaging locations and provide those to the physician when the authorization is requested and reviewed.
*In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of service” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use, “site of care”.
Register Your Site and Update Your Provider Type in OptiNet®
You can register and update your site of care in OptiNet, an online tool available in the Carelon provider portal.
Speed Your Review Request
Our pioneering provider portal technology is the fastest, easiest way to submit your request. An online application, provider portal processes your requests in real time, providing you with a central location to obtain authorizations required by your patients’ health plans. Most online requests are approved at intake in five minutes or less. For requests that require additional consideration, our team of nurses and physicians are available to consult with your practice.
Register or log in to provider portal.