Blue Cross and Blue Shield of North Carolina imaging clinical site of care program effective July 18, 2023 (new effective date)

In a May 2, 2023, post, Blue Cross and Blue Shield of North Carolina announced July 1, 2023, as the effective date for its imaging clinical Site of Care program. Please note that there is a change in the effective date for this program from July 1 to July 18, 2023.

Effective July 18, 2023, Blue Cross NC will review both the medical necessity of the requested service and the clinical criteria to determine if a hospital-based outpatient setting is appropriate for certain imaging services (CTs and MRs) or if a free-standing imaging center is clinically appropriate and an available alternative. These reviews will be administered by Carelon Medical Benefits Management (Carelon).

Carelon will evaluate the clinical information in the request against the appropriate health plan clinical criteria to determine if the selected service should be performed in a hospital-based outpatient setting. If the medical necessity for outpatient hospital Site of Care is not met, the claim may be denied. Before or after the determination, Carelon is available for a peer-to-peer discussion if your office needs it. 

The Site of Care review only applies to services performed in an outpatient hospital setting

For a complete list of procedures subject to Site of Care review, and additional information, such as Frequently Asked Questions, visit the Carelon Radiology resource section.

Blue Cross NC members included in the Site of Care program

All Commercial Fully Insured members are included in the Site of Care program.

For Advanced Imaging Facilities

OptiNet, an online application accessed through the Carelon provider portal, is a proprietary program designed to provide health plans with information on outpatient imaging providers. To register or update your site information, select Access Your OptiNet Registration to launch the OptiNet registration process.

After completing the registration, submit your information. Providers that bill with the following place of services are designated as listed below:

• 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.

Prior to July 18, 2023, advanced imaging providers should review their OptiNet registration to ensure all information is current, including the appropriate place of service code(s); and that the provider type accurately reflects the site’s status as a Freestanding Imaging Center, physician group or hospital.

If you do not find the provider type field populated, you may edit the assessment. Once you have selected the applicable provider type, you will need to submit a statement of attestation to ensure that all information submitted is accurate. Any existing provider assessments will remain in a completed status until an update has been applied to the assessment.

How to Submit a Request for Review

Starting  July 16, 2023, providers may submit order requests for Outpatient Hospital Site of Care for dates of service on or after July 18, 2023, to Carelon using one of the following methods:

Online

The provider portal is available 24/7, fully interactive, and processes requests in real-time using clinical criteria.

By Phone

Call Carelon toll-free at 866-455-8414. Monday through Friday between 8 a.m. - 6 p.m. EST.

Resources for your practice

Our provider website helps you learn more about the program and access helpful information and tools:

• Order entry checklists
• Clinical guidelines
• FAQs

Go to the Carelon Radiology resource section

Upcoming Webinars

Carelon will offer webinars for providers and office staff to learn more about the Site of Care program and using the Carelon provider portal. See below to register for the available webinars:

For More Information

Should you need assistance identifying non-hospital-based facilities in a member’s area in our network, and capable of performing CT and MR services, please contact the Provider Relations Department at the number listed below.

To learn more about Carelon, please visit their Medical Benefits Management page.