Carelon expansion: Prior Authorization and Utilization Review for Cardiology, Genetic Testing, and Radiology
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Maine policy alerts
Know when Blue Cross Blue Shield - Maine releases new policies or updates existing guidance.
Monitor payer policy activity
Announcement that Carelon Medical Benefits Management will perform medical necessity reviews and expanded prior authorization requirements for specified cardiology, genetic testing, and radiology procedures for Anthem Blue Cross members (local fully-insured and select ASO plans) effective August 1, 2023.
Carelon Medical Benefits Management will begin performing clinical appropriateness review and expanded pre-service prior authorization for additional cardiology, genetic testing, and radiology procedures effective August 1, 2023.
Upgrade to the 27th edition of MCG Care Guidelines effective September 1, 2023 for multiple modules including Inpatient & Surgical Care and Chronic Care.
Coverage and Medical Necessity Criteria
Prior Authorization Requirement (Cardiology, Genetic Testing, Radiology)
Covered when services meet medical necessity review and prior authorization requirements:
Carelon will accept requests beginning 2023-07-17
Use of Updated MCG Care Guidelines
Utilization review will use the following clinical guidance:
Some Goal Length of Stay (GLOS) entries are updated and may be more restrictive
These updates expanding Carelon Medical Benefits Management review and prior authorization requirements apply only to local fully‑insured Anthem members and select self‑insured (ASO) members whose services are medically managed by Carelon. They do not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program® (FEP®) members. For benefit determination for a specific member, providers should contact the phone number on the back of the member's ID card.
Anthem will upgrade to the MCG Care Guidelines 27th Edition effective September 1, 2023 for multiple modules. The published tables include revisions to Goal Length of Stay (GLOS) entries. Updates marked with an asterisk (*) indicate changes that "may be perceived as more restrictive." Detailed Anthem customizations and a full summary of changes are available on Anthem's clinical guidelines web page.
Coding and Guideline Identifiers
| J9999 | HCPCS/CPT placeholder used in Clinical Criteria entries (e.g., Adstiladrin) |
| J3490 | HCPCS/CPT placeholder (not otherwise classified) |
| J3590 | HCPCS/CPT placeholder (not otherwise classified) |
| C9399 | HCPCS/CPT placeholder (not otherwise classified) |
| Q5123 | Q-code example listed for rituximab-arrx |
| Q5119 | Q-code example listed for rituximab-pvvr |
| Q5115 | Q-code example listed for rituximab-abbs |
| J0225 | HCPCS code for Amvuttra (vutrisiran) |
| J0741 | HCPCS code for Cabenuva |
| J1551 | HCPCS code for Cutaquig |
| W0099 | MCG reference code listed under Cardiology in adopted clinical guidelines |
| CG-SURG-49 | Anthem clinical guideline identifier |
| CG-SURG-63 | Anthem clinical guideline identifier |
| CG-SURG-97 | Anthem clinical guideline identifier |
What Providers Must Do
Carelon pre-service prior authorization required
Pre-service prior authorization must be obtained from Carelon Medical Benefits Management for additional cardiology, genetic testing, and radiology nonemergency procedures that are scheduled to begin on or after August 1, 2023; Carelon will begin accepting requests on July 17, 2023. See program microsite pages for complete code lists and the clinical guidelines adopted for review.
- Requirement applies to nonemergency modalities scheduled to begin on or after Aug 1, 2023.
- Carelon will accept prior authorization requests beginning Jul 17, 2023 for dates of service on/after Aug 1, 2023.
- Refer to program microsite resource pages for complete code lists and clinical guidelines.
Specialty pharmacy meds added to prior authorization review
Certain specialty pharmacy medications and their associated codes will be added to prior authorization review processes effective for dates of service on and after August 1, 2023; these are managed through the Anthem Medical Specialty Drug Review Team and are listed in Clinical Criteria documents.
- Effective date for inclusion in prior authorization review: Aug 1, 2023.
- See Anthem Clinical Criteria (link in source) for complete lists and details.
- Oncology specialty pharmacy review remains managed by Carelon; non-oncology is managed by Anthem Medical Specialty Drug Review Team.
Submit pre-service reviews via Carelon Provider Portal and microsites
Use the Carelon Medical Benefits Management Provider Portal to submit pre-service review requests online; the portal is available 24/7 and processes requests in real time using Clinical Criteria. Visit the program microsite pages for program-specific resources, order entry checklists, clinical guidelines, and FAQs.
- Register at https://providers.carelonmedicalbenefitsmanagement.com/ to access the Provider Portal.
- Program microsite pages: /genetictesting, /cardiology, /radiology for complete operational guidance and code lists.
Denial risk if pre-service review not obtained
Failure to obtain pre-service review from Carelon for nonemergency procedures scheduled on or after August 1, 2023 may result in claims being subject to prior authorization denial or retrospective review.
- Providers cannot use the Availity ICR tool to pre-certify services managed by Carelon—contact Provider Services or use the Carelon Provider Portal.
- Impacts apply to services for local fully-insured Anthem members and select ASO members managed by Carelon.
Background and Purpose
This notice advises providers that Carelon Medical Benefits Management will conduct clinical appropriateness reviews using the clinical guidelines and medical policies adopted by Anthem (including referenced Anthem guideline identifiers and MCG guidance) for expanded cardiology, genetic testing, and radiology programs. Providers must submit pre‑service prior authorization requests to Carelon for applicable nonemergency procedures scheduled to begin on or after the effective date using the Carelon Provider Portal.
Definitions and Reference Terms
Policy Changes and Effective Dates
Key dates and material changes: Effective August 1, 2023, Carelon Medical Benefits Management will begin expanded pre‑service prior authorization and clinical appropriateness review for additional cardiology, genetic testing, and radiology procedures. Carelon will begin accepting prior authorization requests on July 17, 2023 for services with dates of service on or after August 1, 2023. In addition, utilization review will use the MCG Care Guidelines 27th Edition effective September 1, 2023, which includes revised GLOS entries and other guideline updates.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.