Frequently asked questions
Who is Carelon Medical Benefits Management? How will the program be administered?
Carelon is a leading specialty benefits management company with more than 25 years of experience and a growing presence in the management of radiology, cardiology, genetic testing, oncology, musculoskeletal, sleep management, surgical, and rehabilitation. Our mission is to help ensure health care services are more clinically appropriate, safer, and more affordable. We promote the most appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services. This program will be administered by Carelon.
What is the Sleep Management Program?
The Sleep Program requires prospective clinical review of non-emergency, non-inpatient sleep testing and therapy services. This program will consider the medical necessity of the sleep study as well as the clinical appropriateness of a facility test or a test done in the home. Prior authorization will also be required for any subsequent testing and therapy, both initial and ongoing.
For therapy services, members must meet usage criteria for the continued rental of equipment and replacement of supplies. Servicing physicians’ claims and durable medical equipment (DME) providers’ claims for equipment and supplies will adjudicate based on the approval or denial outcome.
Your participation is required when requesting sleep testing and therapy services for your health plan’s members. Claims submitted for sleep testing and therapy services performed on or after the effective date will not be paid if [prior authorization, or plan-specific term] has not been obtained through the Carelon Sleep Management Program.
How does the program benefit my practice and patients?
Your practice can benefit from participation in several ways, including:
- Improving the clinical appropriateness of sleep testing and therapy through the application of evidence-based guidelines in an efficient and effective review process.
- Monitor and manage patient compliance with sleep therapy.
How does Carelon work with health plans?
Carelon collaborates with health plans to help improve health care quality and manage costs for some of today’s complex tests and treatments, working with physicians like you to promote patient care that’s appropriate, safe, and affordable. In partnership with health plans, we are fully committed to achieving their goals – and yours – to improve health outcomes and reduce costs. Our powerful specialty benefits platform powers evidence-based clinical solutions that span the specialized clinical categories where a health plan has chosen to focus. Our robust medical necessity review process is fully compliant with regulatory and accrediting organizations, while offering a superior experience for you and the health plan’s providers and members.
Which modalities require review?
Contact Carelon to obtain pre-service review for the following sleep therapy testing and treatment services performed in a physician’s office, outpatient hospital department, or a free standing facility:
- Home Sleep Test (HST)
- In-Lab Sleep Study
- Polysomnography (PSG)
- Multiple Sleep Latency Testing (MSLT)
- Maintenance of Wakefulness Testing (MWT)
- Titration Study
- Oral Appliances
- Initial Treatment Orders and Supplies (APAP, CPAP,BPAP)
- On-Going Treatment Orders and Supplies (APAP, CPAP, BPAP)
Services performed in conjunction with emergency room services, inpatient hospitalization, or urgent-care facilities are excluded.
Which members require prior authorization through Carelon?
Please check member benefits and eligibility to determine whether prior authorization is required. Your health plan requires clinicians ordering sleep therapy testing and treatment to request prior authorization for [Health Plan specific LOB]:
- Commercial HMO/POS members
- Commercial PPO/EPO plan members
- Medicare Advantage members
- Medicaid members
- Dual eligible members (Medicare Advantage and Medicaid)
- Federal Employee Plan (FEP) members
Your request will be reviewed by Carelon, and they will notify you of the decision.
Are your clinical criteria available for review?
Yes, the Carelon Clinical Guidelines are easily accessible online. View Sleep Management Clinical Guidelines on the Carelon website.
What methods and resources are used to develop the guidelines?
Development of Carelon Clinical Appropriateness Guidelines involves integration of medical information from multiple sources to support the use of high quality and state-of-the-art sleep testing and therapy. The process for criteria development is based on technology assessment, peer-reviewed medical literature, including clinical outcomes research, and consensus opinion in medical practice.
Who develops the clinical criteria for the program?
Carelon Clinical Appropriateness Guidelines are reviewed annually and updated as needed. New and modified guidelines are reviewed by:
- An independent multidisciplinary physician panel, including primary care and specialty physicians from a variety of geographic areas and practice settings.
- Clinical specialists and leading academic experts
- Client medical directors
In addition, Carelon guidelines are submitted as part of the Carelon accreditation process to the National Committee for Quality Assurance (NCQA) and URAC.
Carelon adheres to the National Academy of Medicine’s (formerly IOM) best practice standards for the development of trustworthy guidelines including a rigorous primary evidence review and a comprehensive evaluation of existing national and specialty society guidelines developed by some of the following organizations:
- Agency for Healthcare Research and Quality (AHRQ)
- American Academy of Pediatrics (AAP)
- American Academy of Sleep Medicine (AASM)
- American College of Cardiology (ACC)
- American College of Physicians (ACP)
- American Heart Association (AHA)
- American Thoracic Society (ATS)
- Centers for Medicare and Medicaid Services (CMS)
- Provider Led Entities (PLEs)
How do I participate in the Sleep Program through Carelon?
The best way to submit a review request is to use the Carelon provider portal.
Provider portal allows you to start a new order, update an existing order, and retrieve your order summary. As an online application, provider portal is available 24 hours a day, 7 days a week. Your first step is to register your practice in provider portal – if you are not already registered. Go to www.providerportal.com to register.
If you have previously registered for other services managed by Carelon (e.g. genetic testing, radiation therapy), there is no need to register again.
Is registration required on provider portal?
Each member of your staff who enters review requests will need to register. Here is how to do it:
- Step one: Go to providerportal.com and select “Register Now” to launch the registration wizard
- Step two: Enter user details and select user role as “ordering provider”
- Step three: Create username and password
- Step four: Enter the tax ID numbers for your providers
- Step five: Check your inbox for an email from Carelon. Click on the link to confirm email address
The provider portal support team will then contact the user to finalize the registration process.
What do I need to register?
- Your email address
- The tax ID number for the providers whose orders you will be entering
- Your phone and fax number
What does the provider portal allow me to do?
- Submit a new order request
- Update an existing order request
- Retrieve your order summary
Will members be able to contact Carelon?
Members should contact your health plan directly if they have any questions.
Who can submit review requests?
Ordering providers and their staff members may submit review requests. Home sleep testing providers, facility-based sleep testing providers, and DME providers are allowed to initiate orders on behalf of the ordering physician.
Can dental providers/dental specialist submit sleep authorization requests?
No, dental providers/specialists may not start a case as the “Ordering Physician” for sleep related tests, studies, and supplies. However, they can meet their patients’ needs as the “Servicing Provider”. For authorization requests, dental providers must list the referring physician as the “Ordering Provider”.
How does a physician office staff member obtain an order number from Carelon and request clinical appropriateness review?
There are two ways providers can contact Carelon to request review and obtain an order number:
Online
- Get fast, convenient online service via the provider portal (registration required). Provider portal is available 24 hrs/day, 7 days/week. Go to providerportal.com to begin.
By phone
When should providers contact Carelon to request clinical appropriateness review?
Providers should contact Carelon to request clinical appropriateness review and obtain an order number before scheduling or performing any outpatient sleep testing and therapy services.
Does Carelon need to know when the procedure is scheduled?
No, although the order number should be issued prior to scheduling the study and/or the procedure. The study and/or the procedure should occur within the timeframe that the order will remain valid.
What information will Carelon require in order to evaluate a request?
Carelon offers a checklist of required information for each sleep related service. This can be found on the resources page.
How does Carelon manage the Rent-To-Own (RTO) period for PAP equipment?
The RTO period is determined based on the Date of Service and Initial Treatment Start Date entered, If the PAP request is within the RTO period, the authorization will include the PAP machine, humidifier, and supplies. If the PAP request is outside the RTO period, the authorization will include supplies only since the member should now have fulfilled their rental requirements and owns the machine.
How can providers determine whether an order number has been obtained for a member?
Providers can contact Carelon or log onto the provider portal to determine whether an order number has been obtained for a member covered under the programs.
Can Carelon handle multiple requests per call?
Yes, requests for multiple members can be made on the same call.
What happens if I do not call Carelon or enter information through the provider portal?
You are encouraged to request prior authorization before the start of services. Retrospective authorization requests may be initiated up to 2 business days after the treatment start date. Failure to contact Carelon for sleep testing and therapy services prior authorization may result in claim denial.
Once I have submitted a request, how long will it take to receive a response from Carelon?
Requests that meet medical necessity criteria:
Requests that meet criteria receive a response immediately in the provider portal or on the phone with the Carelon contact center.
Requests that do not meet medical necessity criteria:
When an order request cannot be approved immediately, you will have the option of discussing your case with one of our clinical experts. A peer-to-peer discussion with one of Carelon’s physician reviewers is always offered before any adverse determination is made. No adverse determination is made until the case has been reviewed by a physician reviewer at Carelon.
How long is an order number valid?
Order numbers issued by Carelon shall be valid for 60, 90, or 365 calendar days. The timeframe is dependent on the sleep study, titration study, or therapy selected within the case.
If the authorization is done via the telephone or via the provider portal, is a letter sent to the provider whether the authorization was approved or denied?
Yes, denial letters will be sent to ordering providers requesting review.
Can an authorization number for a medical necessity determination expire?
Yes, Carelon communicates the expiration date in the approval notification provided for each case.
If a sleep test or therapy is not approved by Carelon, is there an option to appeal the decision?
Yes, providers may call Carelon within 10 calendar days of a denial decision to request a reconsideration. If a reconsideration request does not lead to an approval, or more than 10 calendar days passed, providers and members can submit 1st level appeals to [Health Plan or Carelon]. Denial letters include appeal instructions for both providers and members.
How do I enter a request on the provider portal?
For step-by-step instructions for submitting a case, go to the Reference Desk in the provider portal
Why is a Duplicate Order notification displayed on my Order Request?
This notification will appear when a similar request is on file or the dates from one order to another order overlap. A Carelon clinician will review these cases to verify a duplicate order is not being requested.
Why is my physician showing as Out-of-Network?
The provider is Out-of-Network and the benefits may not apply or may be paid at a lower rate. If you believe your provider is in-network, check with your Network Provider representative to see that your provider is entered into the system as in-network. Provider and member files are sent.
Why is my physician not available for selection in the provider portal?
If your physician is not available for selection, contact provider portal support at 800-252-2021.
What does the Case Status notifications on the Order Summary indicate?
Case Status indicates the overall determination on the request submitted for Carelon review:
- In Progress – case is pending Carelon clinical review. A Carelon MD will review the request. Peer-to-peer may be offered to gather additional clinical information to evaluate the request against medical necessity criteria.
- Completed – case has been reviewed by Carelon and an order number has been given.
- Authorized – case requiring Carelon approval has been authorized.
- Non-Authorized – case requiring Carelon approval does not meet medical necessity criteria and has not been authorized. The entire case is denied.
- Voluntarily Withdrawn – the provider’s office canceled/withdrew the case, following submission.
- Not Reviewed/Error Entry – the case was withdrawn (i.e. accidentally entered, duplicate case entry).
What if I can’t find the modality I’m searching for?
Only modalities managed by Carelon as part of the program can be submitted for review. If you are unable to find the modality in the system, you may call Carelon Customer Service at 800-252-2021 or contact your health plan.
Where can I access additional information?
The provider website offers you all the tools and information you need to get started.
For assistance using the provider portal contact us by email or at 800-252-2021.