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:
- 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.
- 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.