This FAQ was revised on March 13, 2023, to reflect the change from AIM Specialty Health® to Carelon Medical Benefits Management.
The following frequently asked questions (FAQ) were developed to answer questions about the Independence Blue Cross (Independence) Cardiology Utilization Management Program. This program reviews treatment plans for certain non-emergency cardiovascular tests/diagnostic procedures and nonsurgical treatments for obstructive coronary artery disease against clinical appropriateness criteria in order to help ensure that care aligns with established evidence-based medicine. Precertification for these services is delegated to Carelon Medical Benefits Management (Carelon), an independent specialty benefits management company. Carelon reviews procedures using evidence-based Clinical Appropriateness Guidelines to ensure care is medically necessary according to criteria put forth by the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and other professional organizations.
Note: This document will be updated as additional information becomes available.
1. Why did Independence implement a Cardiology Utilization Management Program?
After a thorough internal review of the cardiac services our members currently receive, as well as nationally available data, Independence made the decision to implement a Cardiology Utilization Management Program to ensure members receive care that is appropriate, safe, and affordable. Precertification for cardiology procedures is delegated to Carelon for all Independence members. Carelon will review procedures using evidence-based Clinical Appropriateness Guidelines to ensure care is medically necessary according to criteria put forth by the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and other professional organizations. Precertification for these services was delegated to Carelon on December 18, 2017, for dates of service beginning January 2, 2018.
2. What is the Cardiology Utilization Management Program and how does it benefit health plan members?
The Cardiology Utilization Management Program is intended to ensure that Independence members receive care that is appropriate, safe, and affordable. Carelon is poised to engage physicians and their office support staff in the management of the complexities associated with cardiovascular procedures. Carelon has developed an approach to:
- promote standard of care through the consistent use of evidence-based criteria
- direct care to the most clinically appropriate setting
- facilitate shared decision-making and activate patient involvement through online resources
3. How is the program administered?
Independence has delegated precertification for the Cardiology Utilization Management Program to Carelon.
4. Which cardiac services are included in the Cardiology Utilization Management Program?
Independence requires precertification for percutaneous coronary intervention, diagnostic coronary angiography, and arterial ultrasound through Carelon, with the exception of services performed on an emergent basis. To determine medical necessity for these services, Carelon first utilizes Medicare guidelines (e.g., Local Coverage Determinations, National Coverage Determinations). If no Medicare guidelines exist, Carelon will utilize their Clinical Appropriateness Guidelines.
Independence created commercial and Medicare Advantage medical policies #11.02.27/ MA11.113: Percutaneous Coronary Intervention, Coronary Angiography, and Arterial Ultrasound to detail the precertification requirements for the following services and delegation of this responsibility to Carelon:
- Cardiovascular tests/diagnostic procedures:
- – Coronary angiography
- – Peripheral arterial ultrasound
- Nonsurgical treatments for obstructive coronary artery disease:
- – Percutaneous coronary intervention (PCI), including:
-
o Balloon angioplasty
-
o Stents
-
o Atherectomy
Note: The following outpatient non-emergent diagnostic services are already delegated to Carelon for precertification:
- CT/CTA scans
- echocardiography
- MRA
- MRI
- nuclear cardiology services
- PET scans
- PET/CT fusion
5. When did the precertification requirements for the Cardiology Utilization Management Program begin?
Carelon assumed responsibility for precertification of non-emergency cardiovascular tests/diagnostic procedures and nonsurgical treatments for obstructive coronary artery disease for dates of service on or after January 2, 2018. Servicing provider claims will adjudicate based on the results of the precertification review.
Precertification requirements will continue for existing cardiac and other diagnostic imaging services, which are currently delegated to Carelon.
6. Which providers are affected by these requirements?
Providers who are seeking precertification for the non-emergency cardiac services in the Cardiology Utilization Management Program, including those that perform these services (such as interventional cardiologist), are affected by these requirements.
7. How were providers notified of the Cardiology Utilization Management Program?
On October 3, 2017, the new medical policies were announced to providers via:
- Independence
Medical Policy Portal.
-
Partners in Health UpdateSM, our
online provider newsletter;
- Independence NaviNet® Plan Central in a message containing a summary of the changes to the medical policies and a link to the Medical Policy Portal.
8. How can a provider submit a precertification request to Carelon?
Ordering or performing providers can submit precertification requests for cardiology procedures in one of the following ways:
- PEAR Practice Management.* From the Transactions menu, select Carelon from the Authorizations section.
- Carelon ProviderPortalSM. Go to https://providerportal.com.
The Carelon ProviderPortal is available 24/7 and allows you to open a new order, update an existing order, and retrieve your order summary. Your first step is to register your practice for the ProviderPortal if you are not already registered. Go to https://providerportal.com to register.
Note: If you have previously registered for other services managed by Carelon (e.g., diagnostic imaging, radiation therapy, specialty drugs), there is no need to register again.
9. How does the Cardiology Utilization Management Program work?
Precertification for the listed cardiac services should be requested through Carelon. Carelon will review the procedures to ensure care is medically necessary according to Carelon's evidence-based Clinical Appropriateness Guidelines criteria, which are leveraged from the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and other professional organizations.
When the care requested does not meet clinical criteria, Carelon's established staff of cardiologists provide peer-to-peer consultation to the requesting provider.
10. What happens if the procedures billed are not those that have been authorized?
Prior to performing a service, providers should review the procedure codes and descriptions that have been authorized. If the procedures billed are not those that have been authorized, or within the same procedure code grouping of the codes that have been authorized, the service will be denied appropriately for “no authorization on file."
If there is a discrepancy between the procedure to be performed and the procedure that was preauthorized/preapproved, the provider (performing and/or ordering) should work with Carelon to address the discrepancy and request any necessary changes to the authorization before rendering the service.
In cases where a different or additional service was determined to be necessary during the time of the procedure, the provider has 48 hours post-procedure to submit an update to the authorization.
11. How can I receive a copy of the Clinical Appropriateness Guidelines used by Carelon?
Carelon Clinical Appropriateness Guidelines are available on their website at guidelines.carelonmedicalbenefitsmanagement.com. To request a copy of the Clinical Appropriateness Guidelines, please contact Carelon toll-free at 1-800-252-2021, Monday - Friday 8:00 a.m. - 6:30 p.m. EST.
12. Are providers offered a dispute resolution process?
Yes, providers are offered the standard dispute resolution process as detailed in the Clinical Services – Utilization Management section of the Provider Manual for Participating Professional Providers.
For more information
Please refer to the Medical and Claim Payment Policy Portal to view the most recent version of these medical policies, as they will supersede the information in this FAQ.
*Additional information and self-service training materials for the PEAR Practice Management application on the Provider Engagement, Analytics & Reporting (PEAR) portal are available in the PEAR Help Center.
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