Carelon
Medical Benefits Management manages prior authorization for select services for Premera Blue Cross. Prior authorization is required for certain procedures and services. Contracted providers are financially liable for providing services that are medically
unnecessary. Providers must make prior authorization requests through Carelon for members on plans that require it.
Prior authorization is based on member benefits and eligibility at the time of service. It determines medical necessity, treatment appropriateness, and setting via nationally recognized guidelines.
The following services are subject to review by Carelon:
- Genetic testing
- Imaging (CT scan, echocardiography, MRI, MRA, nuclear cardiology, PET scan)
- Radiation oncology
- Sleep study
View the
code list to see which codes require review.
View
Carelon Clinical Appropriateness Guidelines.
To request a prior authorization, register with Carelon and then submit your request online or by phone at 866-666-0776.
Prior authorization isn't required for the following:
- Emergency room services
- Inpatient hospitalization
- Observation stays
Servicing providers are strongly encouraged to verify that the prior authorization has been received before scheduling and performing services. In addition, servicing providers must submit ordering/referring provider information, per guidelines from the
Centers for Medicare and Medicaid Services (CMS), in boxes 17 and 17b on CMS-1500 forms.
If you have questions, call Carelon at 866-666-0776.
Carelon resources for providers
Carelon Medical Benefits Management is an independent company providing select services to Premera Blue Cross and Premera Blue Cross Blue Shield of Alaska providers.