Your doctor can initiate a request for clinical appropriateness review by contacting Carelon Medical Benefits Management at the phone number indicated on the back of your health plan ID card.
The lists differ depending on the health plan. Your member materials from the health plan (usually the member handbook or the health plan’s website) should have the list of services that require approval. If you have additional questions about which services require approval under a Carelon Medical Benefits Management program, please contact the number on the back of your health plan ID card for your health plan’s member services department
Your doctor is responsible for providing information about you and your health history to Carelon Medical Benefits Management in order to review the request. Carelon Medical Benefits Management talks directly with your doctor, as he/she is responsible for the care that you receive. If you have a question about whether Carelon Medical Benefits Management has approved the request, please contact your doctor.
The clinical guidelines developed by Carelon Medical Benefits Management are available on our website at https://guidelines.carelonmedicalbenefitsmanagement.com.
If staff cannot approve a request, a doctor reviews the information given by your doctor. Your doctor is given a chance to talk to the Carelon Medical Benefits Management doctor. If after talking to your doctor and reviewing the information the service cannot be approved, a Carelon Medical Benefits Management doctor makes the decision.
When Carelon Medical Benefits Management makes a decision that your condition and history does not require the service requested, you are notified of the decision in a letter. Your doctor also receives a copy of the letter that explains why the service was not approved.
When Carelon Medical Benefits Management makes a decision that your condition and history does not support the service requested, you are notified of the decision in a letter, as above. This letter gives you the information on how to appeal the decision made by the Carelon Medical Benefits Management doctor.
