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Precertification has been delegated to Carelon Medical Benefits Management (Carelon) for:

• Cardiology Utilization Management Program
• Musculoskeletal Utilization Management Program
• Precertification for diagnostic imaging services
• Sleep studies

Cardiology Utilization Management Program

Precertification is required for certain cardiovascular tests/diagnostic procedures and certain nonsurgical treatments for obstructive coronary artery disease and is delegated to Carelon for evaluation of medical necessity.

Policies and guidelines

Please review Medical Policy #11.02.27: Percutaneous Coronary Intervention, Coronary Angiography, and Arterial Ultrasound for the specific AmeriHealth policies and a link to Clinical Appropriateness Guidelines that Carelon uses during the precertification process, as well as a listing of procedure codes requiring precertification on our Medical Policy Portal.

To see the complete list of the non-emergent tests and procedures that will be delegated to Carelon and how to submit precertification requests, please review our Cardiology Utilization Management Program: Frequently asked questions (FAQ).​​

Musculoskeletal Utilization Management Program

Precertification is required for certain surgical procedures of the spine and joint and interventional pain management procedures and is delegated to Carelon for evaluation of medical necessity.

Policies and guidelines

Please review Medical Policy #00.01.66: Musculoskeletal Services for the specific AmeriHealth policies and a link to Clinical Appropriateness Guidelines that Carelon uses during the precertification process, as well as a listing of procedure codes requiring precertification on our Medical Policy Portal.

To see the complete list of surgical procedures of the spine and joint and interventional pain management procedures, please review our Musculoskeletal Utilization Management Program: Frequently asked questions (FAQ).

Precertification for diagnostic imaging services

Precertification is required for outpatient nonemergent diagnostic imaging services and certain high-technology radiology services for our managed care members.

Ordering physicians — PCPs or specialists — are required to obtain precertification for the following outpatient nonemergent diagnostic services:

Reviews for the above services will be performed by Carelon according to Medical Necessity criteria.

For more information and a complete list of our high-technology radiology services, please refer to Medical Policy #09.00.46: High-Technology Radiology Services on our Medical Policy Portal.

Sleep studies

Precertification is required through Carelon for sleep studies and continuous positive airway pressure (CPAP) titration studies in facility-based settings. Home-based sleep study tests do not require precertification.

DME providers are required to obtain preapproval/precertification for APAP, BPAP, and CPAP (PAP) machines and their replacement supplies (e.g., tubing, water chambers, face masks).

Policies and guidelines

For more information about sleep testing services, please refer to the following AmeriHealth policies:

• #07.03.01: Home-Based Sleep Studies
• #07.03.05: Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies

To view these policies, visit our Medical Policy Portal. The policies include an updated code list.

Information about Carelon’s Sleep Disorder Management guidelines is included in Medical Policy #07.03.05. Carelon uses these guidelines during the precertification process to determine medical necessity for facility-based sleep testing.

For more information

Please refer to the Clinical Services – Utilization Management or the Specialty Programs sections of the Provider Manual for Participating Profession Providers for more information on preapproval/precertification through Carelon.

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