Blue Cross and Blue Shield of North Carolina (Blue Cross NC) previously announced that Carelon Medical Benefits Management (Carelon) would administer a new Rehabilitation Program for Commercial Fully Insured members effective December, 2024, (see previous original Rehabilitation announcement and announcement changing the effective date from November 2024 to December 2024).
This program will be expanded to include Administrative Services Only (ASO) groups that elect this program beginning July 1, 2025. Providers may begin contacting Carelon to obtain prior authorization for rehabilitation treatment on June 16, 2025, for dates of service on or after July 1.
Providers are strongly encouraged to verify that a prior authorization has been obtained before scheduling and performing rehabilitation services.
This program applies to the following outpatient therapies (including professional and home). Prior authorization requirements are based on the CPT code being filed.
- Physical therapy
- Occupational therapy
- Speech therapy
You can find a listing of updated CPT codes within the program here: Services and CPT codes | Providers | Blue Cross NC.
As a reminder, Autism Spectrum Disorder diagnosis will be excluded from requiring prior plan approval.
To determine if a member requires prior authorization for Rehabilitation 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
It is recommended that providers access the Carelon portal through Blue e to submit prior authorization requests. There will be links to take you directly to the Carelon portal when logging into Blue e.
You can also call our Blue Cross NC eSolutions HelpDesk at 888-333-8594 with any questions.
Also, 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 8:00 AM and 5:00 PM ET.
