We use an independent company, Carelon, to develop or consult on clinical criteria for the following services. Carelon also conducts the medical necessity review for these services. To request prior authorization with Carelon, contact them directly https://www.providerportal.com/.
- Genetic Testing Management 954 and CPT and HCPCS Codes 957
- Quality Care Cancer Program (Medical Oncology) 099 and Supportive Care Treatments for Patients with Cancer 105
- Quality Care Cancer Program (Radiation Oncology) 937 and related CPT and HCPCS Codes 938
- Radiology Imaging Management 968 and CPT and HCPCS Codes 900
- Sleep Disorder Management 969 and CPT and HCPCS Codes 970
Carelon guidelines are reviewed at least annually. The finalized updates are sent to Blue Cross Blue Shield of Massachusetts each quarter. The guidelines are developed with input from providers that have relevant clinical expertise. Carelon guidelines also follow accreditation standards.
New, revised and clarified indications are announced as needed in the monthly medical policy updates announcement table.