The UniCare State Indemnity Plan partners with Carelon Medical Benefits Management (Carelon) to support the review process for certain services and procedures that require preapproval.
Our Provider Reference Sheet identifies which services are reviewed by UniCare, which are reviewed by Carelon, and how much notice is required.
Effective 10/15/2021, Carelon will no longer be administering the Carelon Rehabilitation Program for UniCare members which includes PT, OT and Speech Therapy reviews and authorizations. For services prior to 10/15/2021, please continue to utilize the Carelon Portal. Reconsiderations will be handled by Carelon until November 1,2021. After that date UniCare nurses will complete the reviews. Any new request effective 10/15/21 should be submitted to UniCare by fax to 800-848-3623 or by calling 1-800-442-9300.
Put the Carelon ProviderPortalSM to Work for You
Obtaining prior authorization by phone can be a time-consuming process, from the arduous voice prompts to the length of time waiting to talk to an intake specialist, but there is a better way. The best way to submit a review request is to use the Carelon ProviderPortalSM. It is:
• Available 24/7
• Customizable with physician information
• Easy to use and allows real-time determinations
Register your practice on the portal here.
Learn more about the portal.
Post Claim Clinical Appropriate (PCCA) Reviews
Carelon handles the Post Claim Clinical Appropriate (PCCA) Reviews for CPT codes in our Radiology, Sleep, Genetic Testing and Radiation Oncology solutions.
A PCCA review is for cases that are greater than 2 business days old, but not more than 2 years (730 days) old. To initiate a case, you need the following information:
- Member information
- Patient HCID#
Date of Service
You can use the Carelon ProviderPortalSM or you can call 1-866-766-0247 to initiate the case.
How to Request Preapproval
Here’s who to contact to request preapproval:
- UniCare reviews: UniCare Provider Services at 800-442-9300
- Carelon reviews: Contact Carelon directly through the Carelon web application or call 866-766-0247
- Express Scripts: For review of certain non-oncology specialty drugs for non-Medicare members only, call 855-283-7679
UniCare's partnership with Carelon lets our providers use Carelon's web-based application for services reviewed by Carelon. Providers can log into the Carelon application and complete the intake. In many cases, the entire review and approval process can be done online. Providers who already use Carelon's web application will not have to re-register for UniCare.
Express Scripts, the administrator for the prescription drug plan for UniCare's non-Medicare members, covers and dispenses self- or office-administered specialty drugs (non-oncology). In addition, some specialty drugs require review and dispensing by Express Scripts, for non-Medicare members only. The list of these specialty drugs is updated periodically and posted. Review the Express Scripts Specialty Drug List.
Carelon’s Clinical Information Worksheets and Clinical Guidelines:
- Carelon Clinical Guidelines: Advanced Imaging
- Carelon Clinical Guidelines: Radiation Oncology
- Cardiac Imaging Preapproval Worksheet
- CT/CTA/MRI/MRA Preapproval Worksheet
- Myocardial Perfusion Imaging (MPI) or Stress Echocardiography (SE) Preapproval Worksheet
- PET-PET CT Preapproval Worksheet
- Carelon Clinical Guidelines