If you have questions, call Carelon at 86. In addition, servicing providers must submit ordering/referring provider information, per guidelines from theĬenters for Medicare and Medicaid Services (CMS), in boxes 17 and 17b on CMS-1500 forms. Servicing providers are strongly encouraged to verify that the prior authorization has been received before scheduling and performing services. Prior authorization isn't required for the following: To request a prior authorization, register with Carelon and then submit your request online or by phone at 86. Imaging (CT scan, echocardiography, MRI, MRA, nuclear cardiology, PET scan)Ĭode list to see which codes require review.Ĭarelon Clinical Appropriateness Guidelines.The following services are subject to review by Carelon: It determines medical necessity, treatment appropriateness, and setting via nationally recognized guidelines. Prior authorization is based on member benefits and eligibility at the time of service. Providers must make prior authorization requests through Carelon for members on plans that require it. Prior authorization is required for certain procedures and services.Ĭontracted providers are financially liable for providing services that are medically unnecessary. Medical Benefits Management (formerly AIM) manages prior authorization for select services for Premera Blue Cross. AIM Specialty Health is officially changing its name to Carelon Medical Benefits Management on March 1, 2023.
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