• Curtail the performance of inappropriate advanced diagnostic imaging studies
• Advocate bio-safety issues, including reduction of unnecessary radiation exposure
• Promote the selection of the most clinically appropriate diagnostic imaging services based on a patient's clinical needs
• Encourage standardization of medical practice patterns and reduce variation in clinical evaluation through provider education and collaboration

• Enhance quality of health care for diagnostic imaging studies using evidence-based medicine and outcomes research from numerous resources

The following services are included in the program when they are performed in an outpatient, elective setting:

• Nuclear cardiology
• Nuclear medicine imaging
• Positron emission tomography (PET) studies
• Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA)
• Computerized tomography (CT)/computerized tomography angiography (CTA)

• Stress echocardiography (SE)/resting transthoracic echocardiography (TTE)/transesophageal echocardiography (TEE)

View a complete list of codes that are included in this program on our Pre-authorization List.

Note: A procedure being done for mapping and planning for surgery requires pre-authorization from Carelon.

Pre-authorization is not required for services performed at the following locations:

• Hospital observation
• Inpatient hospitalization
• Emergency room (ER) visits
• Contracted urgent care centers

• Outpatient surgery (hospital or free-standing surgery centers)

The following diagnostic imaging services are excluded from the program but still require pre-authorization:

• Virtual colonoscopy
• Magnetic resonance spectroscopy (MRS)
• Coronary computerized tomography angiography (CCTA)

View codes that require notification in the radiology section of our pre-authorization list.

• Carelon Clinical Guidelines
• Carelon Worksheets

Our contracted providers are required to participate in all quality improvement initiatives and programs as indicated in their provider agreements.

Ordering/referring non-radiological physicians, other health care professionals and/or their trained staff must contact Carelon to request pre-authorization for an elective outpatient diagnostic imaging procedure for any member who participates in this program.

Prior to performing an imaging service covered under the program, it is critical that servicing providers confirm pre-authorization has been received. Review all CPT codes on your Carelon request to confirm the services listed are the ones your facility will provide to the patient. Any corrections must be authorized by Carelon prior to the service. If the services rendered are coded differently than what is authorized, the services may be denied.

Hospital-based imaging providers are strongly encouraged to verify that services have been authorized prior to scheduling the procedure.

• Inpatient diagnostic imaging is not included in this program.
• Hospital-based radiologists who only provide professional services are not required to request pre-authorization.
• Non-radiology specialists will be required to request pre-authorization for outpatient elective advanced imaging services regardless of their affiliation with a facility or practice.

• If a patient is seen in an emergency room (ER) and the ER physician refers the patient to return to the hospital at a later date for advanced radiology services through the hospital's outpatient service, pre-authorization must be obtained from Carelon.

Advanced diagnostic imaging services performed in an urgent care setting don’t require pre-authorization from Carelon. For example, if a patient is referred by an urgent care provider to imaging at:

• The emergency department (ED)
• A free-standing imaging center, or
• The hospital's outpatient service department

Carelon is a leading imaging management company with national experience working with health plans and providers to promote the most appropriate use of advanced diagnostic imaging services. Carelon uses widely accepted clinical content and advanced analytical capabilities.

If all medical necessity criteria are not met or additional information or review is needed, the case will be forwarded to a registered nurse (RN) who will use additional clinical experience and knowledge to evaluate the request against clinical guidelines.

If the RN reviewer still does not believe the service meets the criteria, the case will be forwarded to an Carelon physician reviewer, who will contact the ordering provider directly to discuss the case and diagnostic imaging guidelines prior to issuing a pre-authorization determination.

Carelon's diagnostic imaging utilization management program guidelines serve as a foundation for this discussion.

The physician reviewer can approve the case based on evaluation of information collected or through his or her discussion with the ordering physician or other health care professional. If the Carelon physician reviewer cannot approve the case based on the information previously collected, is unable to reach the ordering provider to discuss the case, or is unable to approve the case based on the information supplied by the ordering provider during the peer-to-peer discussion, pre-authorization will not be approved.

Users can check on the status of a request forwarded for additional clinical review by:

• Checking Carelon's ProviderPortal
• Calling Carelon Customer Service at 1 (877) 291-0509
  

Yes. In the event that a request is transferred to a Carelon physician reviewer for a peer-to-peer discussion, a member of the nursing staff may contact Carelon to discuss the case on behalf of the ordering provider.

Health plan members should contact our Customer Service if they have any questions about our radiology program or their benefits. The phone number is listed on the back of the member ID cards.

Carelon's guidelines for appropriate diagnostic imaging utilization have been reviewed and approved by the National Committee for Quality Assurance (NCQA) and the American Accreditation HealthCare Commission (URAC) and are reviewed annually by:

• Client medical directors
• Physician review panels
• Local imaging advisory councils (representing local physician communities)
• An independent physician review board, including cardiologists, orthopedic surgeons, radiologists, neurologists and neurosurgeons
  

View and download Carelon clinical guidelines.

Development of Carelon's diagnostic imaging utilization management guidelines involves integration of medical information from multiple sources to support the use of high-quality and state-of-the-art diagnostic imaging services. The process for criteria development is based on technology assessment, peer-reviewed medical literature, clinical outcomes research and consensus opinion in medical practice.

The primary resources used for Carelon's guideline development include:

• American Cancer Society
• National Guideline Clearinghouse
• American Heart Association (AHA)
• Society of Nuclear Medicine (SNM)
• American Academy of Pediatrics (AAP)
• American Academy of Neurology (AAN)
• Society of Interventional Radiology (SIR)
• Centers for Medicare & Medicaid Services (CMS)
• American Institute of Ultrasound in Medicine (AIUM)
• Agency for Healthcare Research and Quality (AHRQ)
• American College of Radiology (ACR) appropriateness criteria
• American College of Cardiology (ACC) appropriateness criteria

The radiology program applies to most members residing in Idaho, Oregon, Utah and Washington.

Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials.

Those excluded from this program include:

• Medigap members in Utah
• Any member where we are in the secondary health plan coverage position
• Out-of-network providers for exclusive provider organization (EPO) members (Note: Members on EPO products in Utah do not have out-of-network benefits. Services rendered by out-of-network providers are non-covered services.)
• Members receiving care outside our four-state service area (Note: Out-of-state providers can choose to contact Carelon to receive an order number prior to scheduling the service. As this authorization is not a requirement, if not obtained, the claim will be reviewed for medical necessity once received.)

Carelon offers two methods to easily submit imaging order requests, allowing provider offices to complete imaging order requests in less than five minutes.

• Online: ProviderPortal is available 24 hours a day, seven days a week. Online tools assist with managing radiology cases, such as checking the status of open requests, canceling requests and changing servicing providers.
  • Using the online ProviderPortal is quicker than calling and allows you to easily view and print your pre-authorization request.
• Phone: Contact Carelon's call center at 1 (877) 291-0509.
  

Note: Ordering physicians (those referring the member for an imaging procedure) and servicing providers (those free-standing or hospital facilities that perform imaging procedures) may request pre-authorization.

Ordering/referring provider offices will need to provide the following information when requesting pre-authorization:

• Diagnosis
• Symptoms
• Exam type
• Imaging provider
• Treatment/clinical history
• Patient and ordering physician information
• Other information as requested

If the information provided meets Carelon's clinical criteria and is consistent with our medical policy, the ordering/referring provider office will be asked to select the provider who will perform the imaging study.

Pre-authorizations are valid for 60 days after the date of issue. If the study is not scheduled within this 60-day period, the ordering/referring provider office will need to resubmit a request.

Note: Pre-authorization is not a guarantee of claim payment. The claim will be processed in accordance with the terms of a member's health care benefit plan.

Carelon offers a dedicated web help desk for ProviderPortal users. Representatives are trained to assist with such problems as:

• Data issues
• System outages
• Navigation issues
• Resetting passwords
  

Contact the Carelon Help Desk at 1 (877) 291-0509. At the prompt, select the plan name.

Registration is easy via the ProviderPortal by Carelon. Once you register, you'll receive a password within 24 hours. If you are already registered with Carelon for another health plan, you do not need to re-register; just go to Manage My Groups and choose the tab Add a health plan.