Blue Cross and Blue Shield of North Carolina (Blue Cross NC) previously announced that Carelon Medical Benefits Management (formally AIM Specialty Health) would administer a new Cardiology program for Commercial Fully Insured members effective January 1, 2023 (see previous cardiology program announcement).
Effective January 1, 2024, this program will be expanded to include Administrative Services Only (ASO) plans that elect this program.
Review Requirements
Providers are strongly encouraged to verify that an authorization has been obtained before scheduling or in some cases after performing any elective cardiovascular service.
Contact Carelon to obtain authorization for the following non-emergency cardiovascular services:
- Diagnostic coronary angiography with or without right or left heart catheterization
- Percutaneous coronary intervention (PCI), such as coronary stents and balloon angioplasty
- Arterial duplex
- Physiologic study arterial
- Peripheral revascularization
- Implantable cardioverter – defibrillators
- Cardiac resynchronization therapy
- Permanent pacemakers
You can search the list of codes requiring Prior Plan Approval.
Procedures performed in an inpatient setting (i.e., those services performed during an inpatient stay) or on an emergent basis (i.e., those services performed as part of being evaluated at the ER and prior to the patient’s discharge from the hospital) are not included in the program.
Eligible Members
To determine if a member requires prior authorization for enhanced cardiology services, either search using the member ID on Carelon ProviderPortal℠ or contact Blue Cross NC Customer Service using the phone number on the back of the member’s ID card.
How to Submit a Request for Review:
Starting December 18, 2023, providers can begin submitting requests for dates of service on or after January 1, 2024, for review, via one of the following channels:
Online
The Carelon ProviderPortal℠ is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to Carelon MBM provider portal.
By Phone
Call Carelon toll-free at 866-455-8414, Monday through Friday between 8 AM and 5 PM ET.
For More Information:
For resources to help your practice get started with the cardiology review process, go to the Carelon Cardiology page.
The Carelon provider website provides access to useful information and tools such as order entry checklists and clinical guidelines.
To learn more about Carelon, please visit their Specialty Benefits Management page.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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