Musculoskeletal Program available to ASO plans effective January 1, 2025

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) previously announced that Carelon Medical Benefits Management would administer a new Musculoskeletal (MSK) program for Commercial Fully Insured members effective October 1, 2023, (see previous MSK announcement). 

This program will be expanded to include Administrative Services Only (ASO) groups that elect this program. Providers may begin contacting Carelon to obtain prior authorization for surgeries and pain treatment on December 1, 2024, for dates of service on or after January 1, 2025.

Providers are strongly encouraged to verify that a prior authorization has been obtained before scheduling and performing musculoskeletal services.

 The following non-emergency procedures will require prior authorization through Carelon:

Spine surgery – Cervical, thoracic, lumbar, and sacral

• Bone grafts
• Bone growth stimulators
• Cervical/lumbar spinal fusions
• Cervical/lumbar spinal laminectomy
• Cervical/lumbar spinal discectomy
• Cervical/lumbar spinal disc arthroplasty (replacement)
• Sacroiliac joint fusion
• Spinal deformity (scoliosis/kyphosis)
• Vertebroplasty/kyphoplasty

Joint surgery

• Hip arthroplasty
• Knee arthroplasty
• Shoulder arthroplasty
• Hip arthroscopy
• Knee arthroscopy
• Shoulder arthroscopy
• Treatment of osteochondral defects
• Meniscal allograft transplantation

Interventional pain management

• Epidural injections (interlaminar/caudal and transforaminal)
• Facet joint injections/medial branch blocks
• Facet joint radiofrequency nerve ablation
• Implanted spinal cord stimulators
• Regional sympathetic blocks
• Sacroiliac joint injections
• Monitored Anesthesia Care

Small joint surgery (including all associated revision surgeries)

• Ankle Arthroplasty
• Correction of Hallux Valgus
• Hammertoe repair

To determine if a member requires prior authorization for MSK procedures, search using the member ID on the Carelon Provider Portal⁠ 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: 

Online 

The Carelon Provider Portal⁠ is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to Carelon⁠ Provider Portal.

By Phone 

Call Carelon toll-free at 866-455-8414, Monday through Friday, between 8 AM and 5 PM ET.