Frequently asked questions
Who is Carelon Medical Benefits Management? How will the program be administered?
Carelon is a leading specialty benefits management company with more than 25 years of experience and a growing presence in the management of radiology, cardiology, genetic testing, oncology, musculoskeletal, sleep management, surgical, and rehabilitation. Our mission is to help ensure 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. This program will be administered by Carelon.
What is the Radiology/Advanced Imaging Program?
The Advanced Imaging Program is a utilization management program that requires providers to request prior authorization for advanced imaging services. The requests are evaluated against evidence-based, Carelon Clinical Guidelines.
Your participation is required when requesting diagnostic imaging services for health plan members. Claims submitted for radiology services performed on or after the effective date will not be paid if prior authorization has not been obtained through the Radiology Program.
How does the program benefit my practice and patients?
- Your practice can benefit from participation in several ways, including:
- Improving the clinical appropriateness of imaging services through the application of evidence-based guidelines in an efficient and effective review process.
- Health plans will be utilizing medical policy and/or Carelon clinical guidelines to review for medical necessity.
- Engaging consumers in understanding the range of choices they have in selecting providers and increasing their ability to make informed decisions.
How does Carelon work with health plans?
Carelon collaborates with health plans to help improve health care quality and manage costs for some of today’s complex tests and treatments, working with physicians like you to promote patient care that’s appropriate, safe, and affordable. In partnership with health plans, we are fully committed to achieving their goals – and yours – to improve health outcomes and reduce costs. Our powerful specialty benefits platform powers evidence-based clinical solutions that span the specialized clinical categories where a health plan has chosen to focus. Our robust medical necessity review process is fully compliant with regulatory and accrediting organizations, while offering a superior experience for you and the health plan’s providers and members.
Is this program already in effect?
Contact your plan for details on program effective date. The Carelon call center and website, Carelon provider portal are available for submission of order requests for diagnostic imaging services.
Which modalities require review?
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 for plans that have it.
The following are excluded from the Carelon program:
- Advanced imaging used during interventional procedures or surgery
- Emergency room services
- Inpatient hospitalization
Which health plan members require prior authorization through Carelon?
Please check member benefits and eligibility to determine whether prior authorization is required. Your plan may require clinicians ordering radiology services to request prior authorization for:
- Commercial HMO/POS members
- Commercial PPO/EPO plan members
- Medicare Advantage members
- Medicaid members
- Dual eligible members (Medicare Advantage and Medicaid)
- Federal Employee Plan (FEP) members
Your request will be reviewed by Carelon, and they will notify you of the decision.
Are your clinical criteria available for review?
Yes, the Carelon Clinical Guidelines are easily accessible online. View Advanced Imaging Clinical Guidelines on the Carelon website.
What methods and resources are used to develop the guidelines?
Development of Carelon Clinical Appropriateness Guidelines involves integration of medical information from multiple sources to support the use of high quality and state-of-the-art diagnostic imaging and cardiology services. The process for criteria development is based on technology assessment, peer-reviewed medical literature, including clinical outcomes research, and consensus opinion in medical practice.
Who develops the clinical criteria for the program?
Carelon Clinical Appropriateness Guidelines are reviewed annually and updated as needed. New and modified guidelines are reviewed by:
- An independent multidisciplinary physician panel, including primary care and specialty physicians from a variety of geographic areas and practice settings.
- Clinical specialists and leading academic experts
- Client medical directors
- Local advisory council (representing local physician communities)
- Physician review panels
In addition, Carelon guidelines are submitted as part of the Carelon accreditation process to the National Committee for Quality Assurance (NCQA) and URAC.
How do I participate in the Radiology Program through Carelon?
The best way to submit a review request is to use the provider portal.
Provider portal allows you to start a new order, update an existing order, and retrieve your order summary. As an online application, provider portal is available 24 hours a day, 7 days a week. Your first step is to register your practice in provider portal – if you are not already registered. Go to www.providerportal.com to register.
If you have previously registered for other services managed by Carelon (e.g. genetic testing, radiation therapy), there is no need to register again.
Is registration required on provider portal?
Each member of your staff who enters review requests will need to register. Here is how to do it:
- Step one: Go to providerportal.com and select “Register Now” to launch the registration wizard
- Step two: Enter user details and select user role as “ordering provider”
- Step three: Create username and password
- Step four: Enter the tax ID numbers for your providers
- Step five: Check your inbox for an email from Carelon. Click on the link to confirm email address
The provider portal support team will then contact the user to finalize the registration process.
What do I need to register?
- Your email address
- The tax ID number for the providers whose orders you will be entering
- Your phone and fax number
What does the provider portal allow me to do?
- Submit a new order request
- Update an existing order request
- Retrieve your order summary
Will members be able to contact Carelon?
Members should contact their plan directly if they have any questions.
Who can submit review requests?
Ordering providers and their staff members may submit review requests. When the Ordering provider submits an order requests, we encouraged servicing/rendering providers to verify that prior authorization has been obtained before performing a test for a plan member. Providers can verify prior authorization using provider portal.
How does a physician office staff member obtain an order number from Carelon and request clinical appropriateness review?
There are two ways providers can contact Carelon to request review and obtain an order number:
Online
- Get fast, convenient online service via the provider portal (registration required). Provider portal is available 24 hrs/day, 7 days/week. Go to providerportal.com to begin.
By phone
- If you need any help using the provider portal, call provider portal support at 1-800-252-2021.
When should providers contact Carelon to request clinical appropriateness review?
Providers should contact Carelon to request clinical appropriateness review and obtain an order number before scheduling or performing any elective outpatient imaging and cardiology services.
If I do not complete the pre-exam questions (PEQs) will the results of my order request for cardiac imaging services be impacted?
While the completion of the PEQs for Cardiac CT/CTA, Cardiac PET, MPI and SE is currently voluntary, it is important to note that they facilitate the order review process as these exams are used to assess the risk of Coronary Artery Disease (CAD). Completing the PEQs for these exams will reduce the time it takes to receive your order number.
Since there is no correlation between CAD and all other cardiac exams (TTE, TEE, Blood Pool Imaging/MUGA, and Cardiac MRI), PEQs for adult patients are not included. In addition, because the PEQs do not currently take age into consideration they will not be requested for pediatric patients (under the age of 19).
Does Carelon need to know when the procedure is scheduled?
No, although the order number should be issued prior to scheduling the study and the procedure. Both should occur within the timeframe that the order will remain valid.
What information will Carelon require in order to evaluate a request?
The following information is needed to submit a request to Carelon:
- Member’s identification number, name, date of birth, and health plan
- Ordering provider information
- Imaging provider information
- Imaging exam(s) being requested (body part, right, left or bilateral)
- Patient diagnosis (suspected or confirmed)
- Clinical symptoms/indications (intensity/duration)
For complex cases, more information may be necessary, including results of past treatment history (previous tests, duration of previous therapy, relevant clinical medical history.
Can we request an urgent authorization?
If you have an urgent request, please contact Carelon at 1-800-252-2021. Urgent requests will receive a response within 72 hours of receipt.
How can providers determine whether an order number has been obtained for a member?
Providers can contact Carelon to determine whether an order number has been obtained for a member covered under the programs.
If a service is already authorized by Carelon and needs to be rescheduled beyond the original [30-60-day] authorization period, is a new order number required?
If the date of the service is extended beyond the original [30 or 60] days, a new authorization must be requested through Carelon.
What happens if a member is approved for a specific procedure (for example: CT of the abdomen) and during the course of this procedure, the radiologist or rendering provider feels that an additional procedure requiring precertification (for example: CT of the pelvis) is also needed?
The rendering provider should proceed with the additional procedure. If this occurs, he/she should inform the member’s ordering provider that an additional test was performed on the same day. Carelon must be contacted for an order number for the additional procedure no later than two (2) business days after the services were rendered. The pertinent clinical information supporting the additional procedure must be available at the time Carelon is contacted.
What happens if I do not call Carelon or enter information through the provider portal?
You are encouraged to request prior authorization before the start of services. Retrospective authorization requests may be initiated up to 2 business days after the treatment start date. Failure to contact Carelon for radiology or cardiology prior authorization may result in claim denial.
Once I have submitted a request, how long will it take to receive a response from Carelon?
Requests that meet medical necessity criteria: Requests that meet criteria receive a response immediately in the provider portal or on the phone with the Carelon contact center.
Requests that do not meet medical necessity criteria: When an order request cannot be approved immediately, you will have the option of discussing your case with one of our clinical experts. A peer-to-peer discussion with one of Carelon’s physician reviewers is always offered before any adverse determination is made. No adverse determination is made until the case has been reviewed by a physician reviewer at Carelon.
It is important that when a Carelon RN informs your office (always via phone), that the case pends for peer-to-peer conversation, your ordering physician calls Carelon as soon as possible to discuss it with the Carelon physician. Until we receive a phone call back from the ordering physician (or their representative Physician Assistant or Nurse Practitioner), the case will continue to pend. Non-urgent cases will pend for up to [xx] business days, urgent requests will pend for up to 72 hours of receipt. At that time, if the clinical information requested is not provided and peer-to-peer didn’t take place, the case will be denied. Denial letter will be sent to the member and provider.
How will we know when a peer-to-peer is needed?
When a case pends for review, it will go to an “In Progress” status. Carelon will call the ordering provider requesting a call-back for peer-to-peer review, should it be required.
If the authorization is done via the telephone or via the provider portal, is a letter sent to the provider whether the authorization was approved or denied?
Yes, denial letters will be sent to ordering providers requesting review.
Can an authorization number for a medical necessity determination expire?
Yes, Carelon communicates the expiration date in the approval notification provided for each case.
If a procedure is not approved by Carelon, is there an option to appeal the decision?
Yes, providers may call Carelon within 10 calendar days of a denial decision to request a reconsideration. If a reconsideration request does not lead to an approval, or more than 10 calendar days passed, providers and members can submit 1st level appeals to [Health Plan or Carelon]. Denial letters include appeal instructions for both providers and members.
What is the provider portal?
Provider portal allows convenient, online access to specialty benefits management programs administered by Carelon on behalf of health plan clients.
How do I access provider portal?
Provider portal is available 24/7 to request clinical review of test and treatment requests.
Registration is required. To register or log in, go to: www.providerportal.com
How can I learn how to use provider portal to enter my requests?
For support and training resources, please access the Program Resources section of this site: https://carelonproviderstg.wpengine.com/radiology/program-resources/
Providers also can access a step-by-step tutorial, available on the Provider Resources box, found on the portal home page. Portal login is required. You also may contact the provider portal support team at (800) 252-2021.
How do I enter a request on the provider portal?
For step-by-step instructions for submitting a case, go to the Reference Desk in the provider portal.
Why is a duplicate order notification displayed on my order request?
This notification will appear when a similar request is on file or the dates from one order to another order overlap. A Carelon RN will review these cases to verify a duplicate order is not being requested.
Why is my physician showing as out-of-network?
The provider is out-of-network and the benefits may not apply or may be paid at a lower rate. If you believe your provider is in-network, check with your Network Provider representative at your plan to see that your provider is entered into the system as in-network. Provider and member files are sent by your plan to Carelon.
Why is my physician not available for selection in the provider portal?
If your physician is not available for selection, contact provider portal support at 800-252-2021.
What does the Case Status notifications on the Order Summary indicate?
Case Status indicates the overall determination on the request submitted for Carelon review:
- In Progress – case is pending Carelon clinical review. The request will be reviewed by a Carelon RN (and Carelon MD, if necessary), to clarify/collect additional clinical information via phone call to the provider’s office. Peer-to-peer may be offered to gather additional clinical information to evaluate the request against medical necessity criteria.
- Completed – case has been reviewed by Carelon and an order number has been given.
- Authorized – case requiring Carelon approval has been authorized.
- Non-Authorized – case requiring Carelon approval does not meet medical necessity criteria and has not been authorized. The entire case is denied.
- Voluntarily Cancelled – the provider’s office canceled/withdrew the case, following submission.
- Not Reviewed/Error Entry – the case was withdrawn (i.e. accidentally entered, duplicate case entry).
- Voluntarily Withdrawn – the case was identified as a duplicate due to it be previously submitted.
What if I can’t find the procedure I’m searching for?
Only procedures managed by Carelon as part of the program can be submitted for review. If you are unable to find the diagnosis in the system, you may call Carelon Customer Service at 800-252-2021 or contact your plan.
More Information
Where can I access additional information?
The provider website radiology offers you all the tools and information you need to get started.
For assistance using the provider portal contact us by email or at 800-252-2021.
Should my practice request authorizations for imaging services using the provider portal?
Yes. Your practice should submit authorization requests by accessing the provider portal directly (registration required). Online access is available 24/7 to process orders in real-time, and this is the fastest and most convenient way to request authorization.
How does the imaging clinical site of care review process work?
When your practice submits a request for authorization of certain radiology imaging services and selects a hospital-based outpatient facility as the site of care, a list of appropriate locations will be made available.
If an alternate site of care is not selected, you will be prompted to indicate the reason a hospital-based site of care is medically necessary. If a request for hospital-based site of care does not meet medical necessity criteria, the request will not be approved.
Which imaging services are reviewed for clinical site of care?
Clinical site of care review includes advanced imaging services, i.e., computed tomography (CT) imaging and magnetic resonance (MR) imaging, covered under the medical benefit that require preauthorization.
Who will perform clinical site of care review to determine if the imaging service in an outpatient hospital is medically necessary?
Carelon conducts reviews of advanced imaging services against health plan medical policies and clinical guidelines.
Review for clinical appropriateness of the site of care will be provided by a Carelon physician reviewer if the imaging service is included in the program and the outpatient hospital setting is selected. Note that when the site of care guideline applies to an imaging service, it is an integral component of the medical necessity review. Both the imaging service and the site of care must meet their respective clinical criteria in order for an approval to be issued.
If I select an appropriate site of care location when submitting an authorization request, will the request be reviewed for site of care?
All requests are reviewed against the clinical guideline. However, if the prescribing physician selects a physician office or a free-standing imaging facility, further clinical review will not be required.
Where can providers find the clinical guideline that will apply to clinical site of care review?
When applicable, your patient’s health plan can provide clinical guidelines for clinical site of care review.
Which locations are considered alternate to an outpatient hospital?
Alternate providers include:
- Free-standing imaging facilities – care providers offering imaging services that bill with the place of service as free-standing outpatient (nonhospital providers)
- Physician offices – imaging services occurring in a physician office (typically, the prescribing provider)
How will providers and members be advised of alternate locations for imaging services?
Carelon will provide alternate locations to providers when the imaging order is requested and reviewed.
How will alternate locations be identified for a particular patient?
Alternate provider locations are identified specific to where the patient seeks health care services.
Will this change my patient’s out-of-pocket cost?
Out-of-pocket cost can vary depending on the patient’s benefit plan. Patients may experience reduced out-of-pocket costs when using an alternate site of care provider.
If there is no reduction in my patient’s out-of-pocket cost, can he or she still use a hospital facility?
The approval or denial of the site of care is based on medical necessity. If it is not medically necessary for a patient to have the imaging service provided in a hospital site of care, the request will be denied as not medically necessary, and an alternate free-standing imaging facility will be provided.
Are my patients required to change doctors?
No. The clinical guideline reviews the clinical appropriateness of the site of care (location), so it does not impact the patient’s relationship with their prescribing doctor. Prescribing doctors should consider discussing the appropriate site of care for imaging services with patients.