Blue Cross and Blue Shield of North Carolina musculoskeletal program effective October 1, 2023

At Blue Cross and Blue Shield of North Carolina (Blue Cross NC), we’re always looking for ways to create value for all our stakeholders. With that in mind, we are pleased to announce a Musculoskeletal Program beginning October 1, 2023. 

Effective October 1, 2023, Blue Cross NC will transition review of certain surgeries of the spine and joints, as well as interventional pain management for Fully Insured Commercial members, 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 in an outpatient setting and Spine and Joint Surgery in an outpatient and inpatient admission setting that are scheduled to take place on or after October 1, 2023.

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 medicine and are medically necessary, as well as, provided in the most appropriate clinical setting.

Pre-service review requirements

For surgeries and pain treatment that are scheduled to be rendered on or before September 30, 2023, physicians must contact Blue Cross NC to obtain all prior authorizations. Any authorizations made prior to the transition date of October 1, 2023, will be honored and claims will be processed accordingly.

Beginning September 18, 2023, providers will be able to contact Carelon for prior authorization of surgeries and pain treatments that take place on or after October 1, 2023. Providers are strongly encouraged to verify that a prior authorization has been obtained before scheduling and performing services.

Contact Carelon to obtain pre-service review for the following non-emergency modalities:

Spine surgery – Cervical, thoracic, lumbar, and sacral

• Bone grafts
• Bone growth stimulators
• Cervical/lumbar spinal fusions
• Cervical/lumbar spinal laminectomy
• Cervical/lumbar spinal discectomy
• Cervical/lumbar spinal disc arthroplasty (replacement)
• Sacroiliac joint fusion
• Spinal deformity (scoliosis/kyphosis)
• Vertebroplasty/kyphoplasty

Joint surgery

• Hip arthroplasty
• Knee arthroplasty
• Shoulder arthroplasty
• Hip arthroscopy
• Knee arthroscopy
• Shoulder arthroscopy
• Treatment of osteochondral defects
• Meniscal allograft transplantation

Interventional pain management

• Epidural injections (interlaminar/caudal and transforaminal)
• Facet joint injections/medial branch blocks
• Facet joint radiofrequency nerve ablation
• Implanted spinal cord stimulators
• Regional sympathetic blocks
• Sacroiliac joint injections
• Monitored Anesthesia Care

Small joint surgery (including all associated revision surgeries)

• Ankle Arthroplasty
• Correction of Hallux Valgus
• Hammertoe repair

Members included in the new program

• Commercial Fully Insured members

How to submit a request for review:

Starting September 18, 2023, providers can begin submitting requests for review or verify order numbers using one of the following methods:

Online

The Carelon Provider Portal is available 24/7 via Blue e, fully interactive, and processes requests in real-time using clinical criteria.  

By Phone

Call Carelon toll-free at 866-455-8414, Monday through Friday, between 8 a.m. - 6 p.m. EST.

Upcoming Webinars

Prior to the Carelon Call Center and provider portal going live on September 18, 2023, there will be helpful webinar sessions and Q & A Only sessions for providers and office staff to learn more about each program and how to use the Carelon provider portal. We strongly encourage you and your practice to participate, even if you are already familiar with Carelon and the provider portal through other health plans or specialty programs.

Live Webinar Sessions with Q & A will cover topics such as:

• How the program and preauthorization request process work
• Which members and services will require preauthorization
• Demonstration of the Carelon provider portal and how to enter order requests
• Share additional resources
• Q & A with Carelon Solution Operations leaders

Please register to attend at least one training opportunity. Your facility's attendance at a Carelon training opportunity is highly encouraged. Carelon solution-specific training content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training.

In the weeks leading up to the program go-live, a recording of each solution training will be made available on the Carelon provider portal for all registered provider portal users.

For More Information:

Online

For resources to help your practice get started with the Musculoskeletal and Pain Management Program, go to https://providers.carelonmedicalbenefitsmanagement.com/musculoskeletal/.

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 www.carelon.com.