Our cardiology program is part of our utilization management (UM) programs. Carelon Medical Benefits Management (Carelon) administers the cardiology program, which works to improve health care quality and manage costs for the most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe and affordable. This is accomplished through pre-service medical necessity review of outpatient cardiovascular tests and procedures.
Procedures performed in an inpatient setting or on an emergent basis are not subject to this program’s pre-authorization requirements.
Use the tabs below to learn more about our cardiology program.
- Login to Carelon's ProviderPortal or choose to be routed to Carelon from Availity's Electronic Authorization application via single sign-on
- Phone 1 (877) 291-0509, Monday through Friday, 8 a.m.-5 p.m. (PT)
- View workarounds for Carelon system outages
View codes that require notification in the cardiology section of our Pre-authorization List.
The following services are managed under this program:
- Ambulatory cardiac rhythm monitoring
- Arterial duplex
- Cardiac ablation
- Certain cardiac devices
- Diagnostic coronary angiography with or without right or left heart catheterization
- Dialysis access circuit evaluations and procedures, effective November 1, 2024
- Electrophysiology (EP) studies, effective November 1, 2024
- Physiologic study arterial
- Percutaneous coronary intervention, such as coronary stents and balloon angioplasty and atherectomies; services must be submitted to Carelon for post-service review within 10 days of being performed
- Transcatheter septal defect closure, effective November 1, 2024
- Vascular embolization or occlusion, effective November 1, 2024
Wearable cardioverter defibrillators
Providers ordering the services listed above must first contact Carelon to request pre-authorization. View the codes that require pre-authorization on our Pre-authorization List.
Cardiograph services require pre-authorization as part of our radiology program:
- Stress echocardiography (SE)
- Resting echocardiography (TTE)
- Transesophageal echocardiography (TEE)
Excluded services
Pre-authorization is not required for services performed at the following locations:
- Inpatient hospital
- Hospital observation
- Emergency room (ER) visits
Inpatient or emergent procedures
Procedures performed in an inpatient setting or on an emergent basis do not require pre-authorization from Carelon. Inpatient stays are subject to review by BridgeSpan Health for determining the appropriate length of stay.
Ordering providers (those who refer the member for cardiology services) and servicing providers (those who provide the cardiology services) should submit requests on behalf of members.
Use Carelon's ProviderPortal or call Carelon toll-free at 1 (877) 291-0509, 8 a.m.-5 p.m. (PT) Monday through Friday to request pre-authorization. Requests through the ProviderPortal may receive immediate approval.
- Login or register with Carelon's ProviderPortal
- Phone 1 (877) 291-0509
View workarounds for Carelon system outages
View codes that require notification in the cardiology section of our Pre-authorization List.
If you are already registered with Carelon for radiology authorizations, your registration covers this program as well. All providers who will need access to the Carelon website to obtain authorization or check authorization status must register with Carelon. For large group practices, Carelon can help with the registration process.
- Phone 1 (877) 291-0509
- Register with Carelon