Prior Authorization Responsibility

The ordering or rendering provider is responsible for completing prior authorization. Verify member eligibility and benefits via Availity or the member ID card before requesting authorization. Note: NOC/unlisted codes may still require review at claims submission.

• Provider responsibility: ordering or rendering provider must initiate prior authorization
• Verify eligibility: https://Availity.com or member ID card

Notification timelines

Submit non-urgent prior authorization requests with all required clinical information at least 14 calendar days before the proposed service when possible. For institutional admissions, notify the plan by the next business day or within 48 hours after admission, whichever is earlier. Failure to notify promptly may result in a financial penalty.

• Non-urgent submission timeline: 14 calendar days prior when possible
• Facility admissions: notify by next business day or within 48 hours

How to request prior authorization

Providers may request prior authorization through the plan’s point-of-care portal or by phone. Use Availity (https://Availity.com) or the Carelon provider portal (https://providerportal.com) for real-time online requests. For services reviewed by Carelon Medical Benefits Management, call the Carelon Contact Center at 866-789-0158 (M–F, 8 a.m.–5 p.m. ET). For mental health and substance use disorder prior authorizations, call 800-755-0851. Follow program-specific submission instructions (imaging, MSK, genetic testing, radiation, etc.) and include all required documentation to avoid delays.

• Online (preferred): Availity or Carelon provider portal — fastest method
• Carelon phone: 866-789-0158, M–F 8 a.m.–5 p.m. ET
• Mental health/substance use: 800-755-0851
• Include full clinical documentation and relevant program identifiers (eg, Genetic Testing, Advanced Imaging, Musculoskeletal)

Third-party UM vendor interactions

Carelon Medical Benefits Management is a third-party UM vendor that manages prior authorization for many service categories on behalf of the health plan. When Carelon is listed as the responsible reviewer, follow Carelon submission routes and criteria. Linking to Carelon/third‑party sites subjects users to the external site terms and privacy policies.

• Carelon programs include: Advanced Imaging, Musculoskeletal, Genetic Testing, Radiation Therapy, Oncology Drugs, Vascular Services, Bariatrics, Fertility, Sleep Testing/Therapy, Rehabilitative Services, Diagnostic Imaging Management, and select outpatient UM services

Code responsibility and guideline references (sample)

The policy maps many CPT/HCPCS/PLA codes to an assigned responsible reviewer (Carelon Medical Benefits Management or Anthem) and to applicable guideline sets. When a code lists Carelon or Anthem as the responsible party, prior authorization and medical necessity review will follow the named guideline (for example: Carelon Medical Benefits Management Genetic Testing, Carelon Medical Benefits Management Radiology, Carelon Musculoskeletal, Anthem SURG/CG guidelines, MCG where noted). Always check the code-level entry for the cited guideline before submitting.

• Example code responsibility & guideline references (sample):
• - Genetic testing PLA/CPT (e.g., 0118U, 0120U, 0136U, 0138U, 0314U, 0315U): Responsible = Carelon; Guideline = Carelon Medical Benefits Management Genetic Testing
• - Radiology/imaging codes (e.g., 0331T, 0329T, various CT/MRI/PET codes 70450–78816): Responsible = Carelon Radiology; Guideline = Carelon Medical Benefits Management Radiology or specified Anthem radiology guideline
• - Cosmetic/derm procedures (e.g., 15773, 15780, 15781, 15782): Responsible = Carelon or Anthem; Guideline = Carelon Base Surgical or Anthem ANC.00007/CG-SURG-123
• - Musculoskeletal/spine codes (eg, shoulder arthroscopy 29823–29827, vertebroplasty 22510–22515, spinal fusion/arthrodesis 22600–22612, neurostimulation 63650): Responsible = Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal or Anthem SURG/CG codes

Radiology / Utilization management responsibilities

Radiology services listed in the code tables (CT, MRI, PET, nuclear medicine, CT angiography, and radiation therapy delivery codes) are subject to radiology/utilization management review. Use the Carelon radiology program rules and the referenced Radiology criteria when requesting authorization. Imaging level-of-care and site-of-service rules may apply (eg, outpatient vs inpatient, advanced imaging prior‑authorization programs).

• Radiology codes (selected): CT (70450–70487 series), CT pelvis/abdomen (72191–72197; 74150–74178), PET (78811–78816), specialized PET/brain (78608–78609) — Responsible = Carelon Medical Benefits Management; Guideline = Carelon Radiology
• Radiation therapy delivery/planning codes (77338, 77370–77432, 77407, 77412, 77423–77425, 77373, 77387) — Responsible = Carelon Medical Benefits Management Radiation Therapy; Guideline = Carelon Radiation Therapy or Anthem THER‑RAD policies
• Operational note: verify imaging level-of-care program (eg, Advanced Imaging, Imaging Level of Care) and submit clinical indication and prior imaging when requested

Codes and responsible reviewer mapping (cosmetic/derm procedures)

Certain cosmetic and dermatologic procedure codes require preauthorization and map to either Carelon or Anthem surgical/ancillary cosmetic guidelines. When a code is identified as cosmetic or not covered under the applicable guideline, expect review and possible denial if criteria are not met.

• Cosmetic/derm examples: 15773 (small-area liposuction technique to face/neck/genitalia/hands/feet), 15780–15782 (dermabrasion) — Responsible = Carelon or Anthem; Guideline = Carelon Base Surgical or Anthem ANC.00007/CG-SURG-123
• Action: Provide clinical justification showing medical necessity (eg, scarring, functional impairment) and reference applicable surgical/cosmetic guideline

Codes and responsible reviewer mapping (musculoskeletal/spine)

Musculoskeletal and spine procedure codes are mapped to Carelon Musculoskeletal review or Anthem surgical guidelines. Prior authorization is often required for major spine surgeries, arthroplasties, vertebral augmentation, advanced orthopedics, implantable devices, and many interventional pain procedures. Include supporting imaging, prior conservative therapy documentation, and specialist notes as applicable.

• Selected MSK/Spine examples and responsible party:
• - Arthroscopy/shoulder codes (29822–29827): Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal
• - Vertebroplasty/vertebral augmentation (22510–22515, 22527): Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal
• - Spine fusion/arthrodesis (22600–22612, 22532–22534, 22586, 22590, 22610): Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal or Anthem SURG.00111
• - Neurostimulation and implantable pain device codes (e.g., 63650, 64581, 64590, 64596, 33206–33249 series pacemaker/ICD device management): Responsible = Carelon; Guideline = Carelon Base Surgical / Vascular or Anthem CG-MED-79

Code responsibility and guideline reference (partial)

Code-level entries include assigned responsible party and the guideline to use for clinical review. Always reference the specific code line to determine whether Carelon or Anthem is responsible and which guideline applies (examples below). When a code shows dual responsibility (Carelon or Anthem), follow the instructions provided in the code entry at time of submission.

• Examples of code-to-guideline mapping (partial):
• - 0118U, 0120U, 0136U, 0138U: Responsible = Carelon; Guideline = Carelon Genetic Testing
• - 0314U, 0315U: Responsible = Carelon or Anthem; Guideline = Carelon Genetic Testing
• - 22586: Responsible = Carelon or Anthem; Guideline = Carelon Musculoskeletal or Anthem SURG.00111
• - 33230–33240 series (pacemaker/ICD): Responsible = Carelon Vascular or Anthem; Guideline = Carelon Vascular or Anthem device management

Procedure codes and assigned review responsibility

For many procedures the code table explicitly assigns review responsibility and the guideline to apply — follow that mapping when submitting authorization requests. Include the code, clinical indication, prior conservative care, imaging reports, device specifics, and operative notes as required by the cited guideline to support medical necessity determinations.

• Procedure codes and assigned review responsibility (selected examples):
• - Radiation/therapeutic procedures (55875, 55881–55882; brachytherapy 57155–57156): Responsible = Carelon Radiation Therapy; Guideline = Carelon Radiation Therapy or Anthem THER‑RAD.
• - Spine injections and device implantation (62287, 62290–62323, 62362, 62380): Responsible = Carelon Musculoskeletal; Guideline = Carelon Radiology or Musculoskeletal criteria.
• - Neurolytic and neurostimulation procedures (64600–64640, 64581, 64590): Responsible = Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal or Anthem SURG/ANC guidance