Reminder: Transition to Carelon Medical Benefits Management, Inc. Site of Care Guidelines

Effective April 14, 2024, Wellpoint will transition the Clinical Criteria for site of care reviews to the following Carelon Medical Benefits Management, Inc. Site of Care Guidelines to perform medical necessity/clinical appropriateness reviews for the requested site of care for certain procedures.

Note: These reviews do not apply to procedures performed on an emergent basis.

Carelon also manages the musculoskeletal level of care review using The Carelon Musculoskeletal Appropriate Use Criteria: Level of Care for Musculoskeletal Surgery and Procedures guideline.

Members included in the program

The new review criteria apply to all Wellpoint members currently participating in the above mentioned Carelon Medical Benefits Management programs. To determine if prior authorization by Carelon Medical Benefits Management is required for a member, contact the Provider Services phone number on the back of the member’s ID card.

The following members are excluded: Medicare Advantage (individual and group), Medicare, Medicare supplement, and the Federal Employee Program® (FEP).

Prior authorization requirements

Prior authorization requirements remain the same. For services scheduled to begin on or after

April 14, 2024, care providers must contact Carelon Medical Benefits Management to obtain prior authorization. The requested services received on or after April 14, 2024, will be reviewed with the new Clinical Criteria.

Care providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

• Access ProviderPortal directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. Initiating a request on ProviderPortal and entering all the requested clinical questions will allow you to receive an immediate determination.

For questions related to guidelines, contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.