Your care provider can initiate a request for clinical appropriateness review by contacting Carelon Medical Benefits Management at the phone number indicated on the back of your health plan ID card.
The lists differ depending on the health plan. Your member materials from the health plan (usually the member handbook or the health plan’s website) should have the list of services that require approval. If you have additional questions about which services require approval under a Carelon Medical Benefits Management program, please contact the number on the back of your health plan ID card for your health plan’s member services department.
Your care provider is responsible for providing information about you and your health history to Carelon Medical Benefits Management in order to review the request. Carelon Medical Benefits Management talks directly with your care provider, as he/she is responsible for the care that you receive. If you have a question about whether Carelon Medical Benefits Management has approved the request, please contact your care provider.
The clinical guidelines developed by Carelon Medical Benefits Management are available on our website at https://guidelines.carelonmedicalbenefitsmanagement.com .
If our staff cannot approve a request, a doctor reviews the information provided by your care provider to confirm the decision. For further consultation, your care provider is given an opportunity to speak with the Carelon Medical Benefits Management doctor. If, after discussing with your care provider and reviewing the information, the service cannot be approved, the Carelon Medical Benefits Management doctor makes the final decision.
When Carelon Medical Benefits Management makes a decision that your condition and history does not require the service requested, you are notified of the decision in a letter. Your care provider also receives a copy of the letter that explains why the service was not approved.
When Carelon Medical Benefits Management determines that your condition and history do not support the requested service, you are notified of the decision in a letter, as previously described. This letter provides information on how to appeal the decision made by the Carelon Medical Benefits Management doctor.
