Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to promoting care that is appropriate, safe, and affordable for our members. With that in mind, we are pleased to announce that Carelon Medical Benefits Management (Carelon) will review authorization of cardiovascular services for our Medicare Advantage, Experience Health, and D-SNP plans for services performed on or after July 1, 2026.
The goal of this new review process is to improve the clinical appropriateness of cardiovascular services through the application of evidence-based guidelines with expert cardiologist assessment in an efficient and effective review process.
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 elective, non-emergent outpatient and observation cardiovascular services, such as:
- Diagnostic Coronary Angiography with or without right or left heart catheterization
- Percutaneous Coronary Intervention (PCI), such as coronary stents and balloon angioplasty
- Peripheral Revascularization
- Cardiac Devices such as Mobile telemetry, Implantable Defibrillators & Pacemakers
- Cardiac Resynchronization Therapy
- Electrophysiology Studies and Procedures such as Cardiac Ablations
You can search the Blue Medicare Carelon Prior Authorization Code List for the complete listing of codes.
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 the Carelon Portal via Blue e 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 June 15, 2026, providers can begin submitting requests for review or verify order numbers online or by phone.
The Carelon Provider portal access via Blue e is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. Or providers can 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 Carelon Provider Portals and Resources.
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 Carelon Medical Benefits Management.
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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