09/30/2024
Effective Jan. 1, 2025, Carelon Medical Benefits Management will do a medical necessity review including site of care when you request eligible computed tomography, computed tomography angiography, magnetic resonance imaging and magnetic resonance angiography imaging services that require a prior authorization or are applicable for a recommended clinical review in a hospital-based outpatient setting for certain commercial members. These additional reviews will help our members get the right care in the right 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 or recommended clinical review code lists on our Utilization Management page.
Always check eligibility and benefits first through Availity® Essentials or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements or if service is eligible for recommended clinical review and if managed by BCBSTX or a utilization management vendor.
Even if prior authorization isn’t required for a commercial 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.
Services performed without required prior authorization or optional RCR that do not meet post service medical necessity or site of care criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
Note: These changes do not apply to Federal Employee Program® or Medicare Advantage or Medicaid members.
Please note that checking of eligibility and benefits information, and/or the fact that any pre-service review has been conducted, 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 applicable on the date services were rendered.
Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.
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 BCBSTX.
BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.