Frequently asked questions

We review certain treatment plans against clinical appropriateness criteria to help ensure that care aligns with established medical best practices. To request review of treatment plans, providers should contact Carelon for the radiation therapy modalities and services as noted below:

Pre-certification
Providers contact Carelon to obtain pre-certification for the following non-emergency, outpatient radiation therapy modalities:

• • All forms of external beam radiation therapy (EBRT)
    • 3D Conformal Radiation Therapy
    • Intensity Modulated Radiation Therapy (IMRT)
    • Stereotactic Radiosurgery (SRS)
    • Stereotactic Body Radiation Therapy (SBRT)
    • Proton Beam Therapy
  • Brachytherapy
  • Intraoperative radiation therapy (IORT)
  • Selective Internal Radiation Therapy (SIRT)
  • Fractionation review for EBRT or IMRT to treat prostate, breast, and non-small cell lung cancers, as well as bone metastases

  Services that may also require review:

  • Image guided radiation therapy (IGRT)
  • Special consults and procedures associated with radiation therapy
  • Select Radiopharmaceuticals, including:
    • Lutathera: Lutetium Lu 177 dotatate
    • Pluvicto: Lutetium Lu 177 vipivotide tetraxetan
    • Xofigo: Radium 223 dichloride
    • Sodium Iodide 131: Sodium iodide I-131

  *Note: procedures reviewed may vary by health plan

Radiation therapy performed as part of an inpatient admission will be reviewed through the patient’s health plan, if applicable.

*Pre-notification for 3-D Conformal Radiation Therapy (EBRT) For EBRT, pre-certification is required for procedures involving bone metastases, prostate cancer, lung cancer (NSCLC), and breast cancer.

We are collecting this information to obtain a more complete understanding of the broad range of radiation therapy services being delivered for health plan members. Review will be performed to ensure the ordering physician is aware of alternative treatments where applicable. Once review is completed a confirmation/tracking number will be issued. Claims will not be denied as a result of the pre-notification process.

Please contact Carelon through the following processes:

• Online via Carelon provider portal. Provider portal is available 24/7. It is fully interactive, processing requests in real-time. The provider portal may be accessed directly at www.providerportal.com. Registration is required.
• By phone, using the dedicated phone number available from your patient’s health plan.

Providers are strongly encouraged to verify that an order number has been obtained before initiating, scheduling and performing services.

Please refer to the Radiation Oncology Request Checklist on our Resources page.

For orders requiring prior authorization, Carelon will review requests against Carelon proprietary clinical guidelines as well as health plan medical policy, and/or Local Coverage Determinations (LCDs) if applicable.

If the request meets medical necessity criteria based on the information submitted by the ordering provider’s office, the provider will receive an order number. If the request does not immediately meet criteria, the case will be forwarded to a nurse for additional clinical review. Nurse reviewers will request additional information regarding the case. If the additional information necessary confirms that the case is consistent with program guidelines, the provider will then receive an order number.

If, with the additional information the case still does not meet criteria, the case will be forwarded to a board-certified Radiation Oncologist. Upon review, the physician reviewer may issue an order number or issue an adverse determination. The ordering provider will be notified of the final outcome for the request.

For EBRT, pre-certification is required only for procedures involving bone metastases, prostate cancer, lung cancer (NSCLC), and breast cancer. Additionally, we are requesting that providers contact Carelon to review all other 3D-conformal therapy requests on a voluntary basis.

Requests that meet criteria will receive an instant approval when submitted via the provider portal or on the phone with Carelon contact center representative.

Upon approval, Carelon will provide the ordering physician with an order number, which will be valid for 90 days from the initial treatment date. Issuance of an order number is not a guarantee of payment. When submitted, the claim will be processed in accordance with the terms of the member’s health benefit plan.

The order reflects an expected maximum duration of treatment of 90 days. If treatment continues beyond 90 days, please submit a new treatment regimen request to Carelon. Most users will find the most efficient way to track the order request time period is to save the summary page that you receive from the provider portal, after completing your initial order in your patients’ charts, so that the information to report continuation of treatment is easily available.

Yes, a letter will be sent to the ordering provider, at a minimum. Some health plans also require letters to be sent to the servicing provider and member.