![]() For joint and spine surgery prior authorizations, if an outpatient or inpatient facility stay is being requested, providers will contact Carelon first for medical necessity determination, then contact BCBSTX for final determination of length of stay & the level of care.Ordering physicians or servicing providers (facilities) may submit prior authorization requests.Services can vary depending on the patient benefits. Providers need to determine if prior authorization is required through Carelon before rendering services.Joint and Spine Surgery, and Pain Management.Outpatient Services Impactedįor services noted below select the category on the Carelon website. ![]() With Carelon administering prior authorizations, we can optimize our programs, further ensuring that care aligns with established evidence-based medicine. Employees Retirement System of Texas (ERS) participants.Teacher Retirement System of Texas (TRS) participants.Blue Premier SM and Blue Premier Access SM.Carelon Prior Authorization ProgramĬarelon provides required prior authorization review and approvals for select outpatient services. Prenotification Radiology Quality Initiative (RQI) program for outpatient high-tech diagnostic imaging servicesīe sure to verify eligibility and benefits and check prior authorization/prenotification requirements through Availity ® or your preferred vendor to determine if a prior authorization or an RQI is needed for the patient depending on their benefit plan.Prior authorization and post service medical necessity review for certain outpatient services.Carelon is a specialty health benefits company that works with leading insurers to improve health care quality and manage costs for today’s most complex and prevalent clinical guidelines, tests and treatments, helping to promote care that is appropriate, safe and affordable.
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