Frequently asked questions
How does it benefit health plan members?
This Surgical Procedures review is here to help support you in helping your patients receive the care that is appropriate, safe, and affordable. It promotes services that align with the standard of care through the consistent use of evidence-based criteria.
How will the review be administered?
The Surgical Procedures review is administered by Carelon Medical Benefits Management on behalf of your patients’ health plan. Participating is most easily managed using the Carelon provider portal, available 24 hours a day, 7 days a week.
Who is Carelon?
Carelon, a separate company, collaborates with payors to help improve health care quality and manage costs for some of today’s complex tests and treatments, promoting care that’s appropriate, safe, and affordable.
What kind of cases are reviewed?
Upper gastrointestinal (GI) endoscopy, also referred to as esophagogastroduodenoscopy (EGD). Modalities may vary by health plan. Refer to the Resources tab for more information.
How does the Surgical Procedures review work?
Your practice contacts Carelon to request a review of included procedures. You will be asked to submit certain information about your patient and their clinical condition. The information you enter is compared against evidence-based clinical guidelines. If the information provided meets criteria in the applicable clinical guideline(s), an order number will be issued. When the care requested does not meet clinical criteria, our established staff of physicians can provide a peer-to-peer consultation.
For some health plans, the program also includes a member engagement initiative called Specialty Care Shopper. When you recommend certain procedures, Specialty Care Shopper offers cost information to your patients about nearby facilities that offer surgical procedures.
Is your clinical criteria available for review?
Yes, our clinical guidelines are easily accessible online. You can find the clinical guidelines that apply to your health plan under Resources. These can also be found within the provider portal, when clinical review requests are initiated.
Which procedures require review?
Treatment of conditions that present in the emergency room or as part of a hospital in-patient stay do not require pre-authorization.
You can find the CPT codes for the procedures that apply to your health plan under Resources.
Does the review include inpatient or observation services or services rendered on an emergency basis?
No. The review includes only elective procedures performed on an outpatient basis (hospital, ambulatory surgery center, or physician office).
How do I participate in the Surgical Procedures review through Carelon?
The best way to submit a review request is to use the provider portal.
Provider portal allows you to open 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 (diagnostic imaging, radiation therapy, specialty drugs), there is no need to register again.
Is registration required at provider portal?
Each member of your staff who enters review requests will need to register. Here’s how to do it:
- Step one: Go to www.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 user name 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
The provider portal allows you to:
- Submit a new order request
- Update an existing one
- Retrieve your order summary
How do I use the provider portal to submit my treatment?
Once registered, log in to the provider portal to begin the order entry process. You will be guided through a series of questions regarding your patient, the requested procedure, and your patient’s clinical condition.
What information do I need to submit to Carelon?
Our simple checklists show exactly what information you will need.
What happens if I do not call Carelon or enter information through the provider portal?
If you call the health plan directly, you will be directed to the provider portal or to call the Carelon contact center.
How will I know if my order request met clinical criteria and was approved?
When you request review of a procedure, a determination will be made based on the information you provide regarding your patient’s specific clinical condition. If the information provided meets clinical guidelines and is consistent with the health plan’s medical policy, an order number will be issued.
If all criteria are not met or additional information or review is needed, the case is forwarded to a registered nurse (RN) who uses additional clinical experience and knowledge to evaluate the request against clinical guidelines. The nurse reviewer has the authority to issue order numbers in the event that he or she is able to ensure that the request is consistent with our clinical criteria and health plan medical policy.
If an order number still cannot be issued by the nurse, they contact you to schedule a peer-to-peer discussion with a Carelon physician reviewer (MD). The physician reviewer can approve the case based on a review of information collected or through their discussion with the ordering or servicing physician.
In the event that the Carelon physician reviewer cannot approve the case based on the information previously collected, is unable to reach you to discuss the case, or is unable to approve the case based on the information supplied by you during the peer-to-peer discussion, the physician reviewer will issue a denial for the request
How long is my order number valid?
Unless otherwise required by state law, order numbers are valid for 60 calendar days. Carelon communicates the expiration date in the approval notification for each case.
Can an order number expire?
Yes, Carelon communicates the expiration date in the approval notification provided for each case.
What are my options if a review request does not meet clinical criteria?
Your office can contact Carelon to request a peer-to-peer discussion before or after the determination. When there is a request for a peer-to-peer consultation, we will make an effort to transfer the call immediately to an available Carelon physician reviewer. When a physician reviewer is not available, we will offer a scheduled call back time that is convenient for the practice.
Specialty Care Shopper, our member engagement initiative, supports your efforts to reinforce important information about the surgeries and treatments you recommend. This initiative is designed to educate members and allow for greater cost transparency.
How it works:
For health plans enrolled in Specialty Care Shopper, members are contacted by telephone and are provided cost information on both the selected facility as well as nearby surgical facilities, based on the order requests you submit.
Members will have an opportunity to note any questions and concerns, which they can discuss with you at their next appointment. This gives you the opportunity to discuss any additional education and information required.