New Surgical Program effective November 1, 2024

At Blue Cross and Blue Shield of North Carolina (Blue Cross NC), creating value for our stakeholders is a priority. With this in mind, we are pleased to announce a new Surgical Program from Carelon Medical Benefits Management (Carelon) beginning November 1, 2024.

Effective November 1, Blue Cross NC will transition medical necessity review of certain surgical services for Commercial Fully Insured members to Carelon. The advantages of the program include:

• Improving the clinical appropriateness of certain surgical services through the application of evidence-based guidelines in an efficient and effective review process.
• Carelon clinical guidelines will be used to review for medical necessity.
• Engaging providers and members in understanding the range of choices they have in selecting the setting where procedures are taking place and increasing their ability to make informed decisions.

For services that are scheduled to begin on or after November 1, 2024, all providers must contact Carelon to obtain pre-service review for the following non-emergency modalities:

• Upper GI Endoscopy (EGD)

Training Webinars

To help you prepare for this program, Carelon will host a series of live webinar sessions and Q & A only webinar sessions that are designed for providers and office staff who will be requesting prior authorization. The webinars will cover topics such as:

• How the program and preauthorization request process work
• Which members and services will require preauthorization
• Demonstration of the Carelon provider portal and how to enter order requests
• Share additional resources
• Q & A with Carelon’s Solution Operations Leaders

We strongly encourage you and your practice to participate, even if you are already familiar with Carelon and the provider portal through other health plans or specialty programs.

How to Access the Webinars

Your attendance at a Carelon training opportunity is highly encouraged. Please register to attend at least one training opportunity. Carelon solution-specific training content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the session.

In the weeks leading up to the program go-live, a recording of each solution training will be made available on the Carelon provider portal for all registered provider portal users.

How to Submit a Request for Review:

Starting October 21, 2024, providers can begin submitting requests for review or verify order numbers to Carelon using one of the following methods:

Online
The Carelon provider portal is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. Visit the Carelon provider portal to register.

By Phone
Call Carelon toll-free at 866-455-8414, Monday through Friday between 8 am – 5 pm ET.

For More Information:

Online
Carelon’s provider website helps you learn more about the program and provides access to useful information and tools such as order entry checklists and clinical guidelines.