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 musculoskeletal services for our Medicare Advantage, Experience Health, and D-SNP plans for services performed on or after September 1, 2026.
Effective September 1, 2026, Blue Cross NC will transition review of certain procedures of the spine and joints, as well as interventional pain management for Medicare Advantage, Experience Health, and D-SNP, to Carelon Medical Benefits Management (Carelon). Carelon works with leading insurers to improve health care quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.
As a provider of musculoskeletal procedures, Blue Cross NC requires that you contact Carelon for pre-service review of all Interventional Pain Management and Spine and Joint Procedures scheduled to take place on or after September 1, 2026.
Your practice can benefit from this program since these services are reviewed against clinical appropriateness criteria to ensure the care aligns with established evidence-based guidelines and are medically necessary.
Pre-service review requirements
For procedures and interventional pain management that are scheduled to be rendered on or before August 31, 2026, physicians must contact Blue Cross NC to obtain prior authorizations. Any authorizations made prior to the transition date of September 1, 2026, will be honored and claims will be processed accordingly.
Beginning August 10, 2026, providers will be able to contact Carelon for prior authorization of surgeries and pain treatments that take place on or after September 1, 2026. Providers are strongly encouraged to verify that prior authorization has been obtained before scheduling and performing services.
Contact Carelon to obtain pre-service review for the following non-emergency modalities, such as:
- Spine Procedures
- Joint Procedures
- Interventional Pain Management
- Small Joint Procedures
Members included in the new program
- Medicare Advantage
- D-SNP
- Experience Health
This program is also currently active for Commercial Fully Insured plans and certain Administrative Services Only (ASO) plans. It is not available to the Federal Employee Program (FEP) plan.
How to submit a request for review
Starting August 10, 2026, providers can begin submitting requests for review or verify order numbers online or by phone.
The Carelon Provider Portal is available 24/7 via Blue e, 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 6 PM ET.
For more information
For resources to help your practice get started with the Musculoskeletal and Pain Management Program, go to the Carelon Musculoskeletal page.
The Carelon provider website helps 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 the Carelon website.
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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