Carelon (formerly AIM) Quality Care Cancer Program (Radiation Oncology)
This policy governs prior authorization and utilization management of outpatient radiation oncology services delegated to Carelon Medical Benefits Management for Blue Cross Blue Shield of Massachusetts Commercial and Medicare Advantage members.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage condition
Covered when prior authorization is obtained per Carelon Clinical Guidelines.
Guidelines reference peer-reviewed literature and organizations such as ASCO and NCCN.
This inventory entry notes a Radiation Oncology medical policy that is managed directly by Blue Cross. For this specific policy, prior authorization is not required from Blue Cross or Carelon Medical Benefits Management.
The policy referenced is maintained on the Blue Cross website and is managed by Blue Cross rather than delegated to Carelon; therefore, it does not require prior authorization through Carelon or Blue Cross’ delegated processes.
Coding
| See Carelon Quality Care Cancer Program CPT and HCPCS Codes (Radiation Oncology) , #938 |
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required for outpatient radiation oncology treatments for Commercial and Medicare Advantage products and must be requested via Carelon Medical Benefits Management (AIM). Authorization requests may be submitted through the AIM ProviderPortal, via the link on the Blue Cross Blue Shield of Massachusetts Provider Central site (eTools → Carelon Medical Benefits Management → Go Now), or by calling the AIM Contact Center (Mon–Fri, 8 a.m.–6 p.m. ET) at 1-866-745-1783. Registration for the AIM ProviderPortal is required if not already completed.
- Affected products: Commercial Managed Care (HMO, POS), Commercial PPO/EPO, Medicare Advantage HMO and PPO
- AIM ProviderPortal: registration required
- AIM Contact Center: 1-866-745-1783 (Mon–Fri, 8 a.m.–6 p.m. ET)
Provider Action
Providers must initiate prior authorization requests through Carelon (AIM) before delivering outpatient radiation oncology services to members covered under the specified products. Ensure the request follows Carelon's Clinical Guidelines and includes all necessary clinical information to support medical necessity.
- Submit authorization requests via AIM ProviderPortal, Provider Central link, or AIM Contact Center
- Include diagnosis, treatment intent, proposed radiation plan, and supporting clinical documentation
Medical Record Documentation
Member medical records must document that the services provided were medically necessary. All supporting documentation used to justify the authorization request and services rendered must be retained and made available upon request.
- Retain records of diagnosis, treatment plan, consent, simulation, dose/fractionation, and treatment delivery
- Documentation must align with Carelon Medical Benefits Management Clinical Guidelines
Documentation Audit Risk
Failure to produce requested documentation or to obtain required prior authorization may result in denial or retraction of payment. Blue Cross Blue Shield of Massachusetts reserves the right to audit services provided and request supporting records regardless of provider participation status.
- Denial or retraction of payment possible if documentation is unavailable or authorization not obtained
- Audits may occur regardless of provider participation status
Background
Carelon Medical Benefits Management’s Clinical Guidelines for Radiation Oncology establish the medical necessity criteria used for outpatient radiation oncology services when Carelon is the delegated manager. Those guidelines are the reference standard for authorization decisions in delegated cases; however, the specific Radiation Oncology medical policy noted here is managed by Blue Cross and does not require prior authorization through Carelon.
Definitions
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