Sept. 26, 2024
We are expanding utilization management reviews for some Advanced Imaging Site of Care services for some commercial, non-HMO members. These additional reviews will help our members get the right care in the right setting.
Effective Jan. 1, 2025, we will require a medical necessity review from Carelon Medical Benefits Management when you request eligible computed tomography, computed tomography angiography, magnetic resonance imaging and magnetic resonance angiography imaging in a hospital-based outpatient setting.
Carelon will review your request for medical necessity and determine if the service requires an outpatient hospital setting, or if there are available freestanding alternatives. Carelon will use its “Site of Care for Advanced Imaging” clinical guidelines to conduct its review. You may request a peer-to-peer review from Carelon before or after the determination.
For advanced imaging facilities: If your facility bills as a freestanding imaging center, or bills with the following place of service designations, we recommend you register with OptiNet® by Dec. 1, 2024:
- Place of service codes 11, 49 or 81 are designated as a Freestanding Imaging Facility / Physician Group
- Place of service codes 19 or 22 are designated as an Outpatient Hospital Department
OptiNet is Carelon’s online assessment tool that collects modality-specific data from imaging providers.
For more information, refer to our updated prior authorization code lists on our Support Materials (Commercial) web page.
Not included: These changes don’t apply to Federal Employee Program®, Medicare Advantage or Illinois Medicaid members.
Always check eligibility and benefits first: Use Availity® Essentials or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Even if prior authorization isn’t required for a commercial non-HMO member, you still may want to submit a voluntary recommended clinical review request. This step can help avoid post-service medical necessity review. Learn more about Recommended Clinical Review here.
Services performed without required prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
Carelon Medical Benefits Management is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.