Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs, and deliver access to a better health care experience for our members.  One way in which we can achieve this is to partner with providers to utilize care sites beyond the hospital when performing some surgical procedures. 

Effective July 1, 2025, when prior authorization is requested for pain management and joint surgery procedures already included under the Carelon Medical Benefits Management (Carelon) Musculoskeletal Program, an additional site of care review will be performed when the request is for a hospital-based outpatient setting. 

In addition to determining medical necessity of the requested procedure, as Carelon does today, they will evaluate the clinical information in the request against the appropriate Carelon clinical guidelines to determine if the selected procedure requires the service to be rendered in a hospital-based outpatient setting. When medical necessity criteria for pain management administration or joint surgery in a hospital-based outpatient setting are not met, an alternative less-intensive site of care should be utilized, such as an ambulatory surgery center (ASC) or provider office. Carelon is available for a peer-to-peer discussion before or after the determination, in the event your office wishes to speak with Carelon.

The Musculoskeletal site of care review only applies to select Interventional pain management procedures and joint surgery procedures when requested in an outpatient hospital setting, including but not limited to: 

Interventional pain management

• Epidural injections
• Facet injections
• Radiofrequency nerve ablation
• Regional sympathetic blocks
• Sacroiliac joint injections

Joint surgery

• Joint arthroscopies (hip, knee, shoulder)
• Select small joint procedure

For a complete list of procedures subject to site of care review, and additional information, such as Frequently Asked Questions, visit the Carelon Musculoskeletal Resources webpage.  

Members included in the site of care program

This program will apply to all Commercial Fully Insured plans. It does not apply to our Medicare Advantage plans, Dual Special Needs Plan (DSNP), Employer Group Waiver Plan (EGWP), Federal Employee Program (FEP) plan, and Administrative Services Only (ASO) plans.  

How to Submit a Request for Review

Starting June 16, 2025, providers can begin submitting requests for review or verify order numbers using one of the following methods:

Online 

Access Carelon’s portal through Blue e, which is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. 

By Phone

Call Carelon Medical Benefits Management toll-free at 866-455-8414. Monday through Friday between 8:00 a.m. – 6:00 p.m. EST.

Provider Training Opportunities 

Prior to the Carelon Call Center and provider portal going live on June 16, 2025, there will be helpful webinar sessions and Q&A only sessions for providers and office staff to learn more about each program and how to use the Carelon provider portal.  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.

Live webinar sessions with Q&A 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 our Solution Operations Leaders

Please register to attend at least one training opportunity. Your facility’s attendance at a Carelon training opportunity is highly encouraged. 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 training. 

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. 

For More Information

Online

For resources to help your practice get started with the Musculoskeletal and Pain Management Program, go to the Carelon provider website. 

The Carelon provider website can help you learn more and provides access to useful information and tools such as order entry checklists, clinical guidelines, and FAQs.

To learn more about Carelon, please visit www.carelon.com.