Provider Central

For high technology radiology (HTR) services provided in the elective, outpatient setting, we require prior authorization for most commercial HMO/POS, PPO, and Medicare Advantage HMO and PPO. Carelon Medical Benefits Management administers this program on our behalf.

Requirements do not apply to Federal Employee Program members. In addition, prior authorization is not required for any member for HTR studies performed:

• In the emergency department
• As part of observation
• In an inpatient setting
• As part of an outpatient surgery

Copayments may apply
For some plans, a member may be responsible for a copayment for certain outpatient radiology studies. As always, check eligibility and benefits before rendering service to determine the member’s cost-share for HTR services.

Ordering clinicians should use eligibility and benefit technologies like ConnectCenter—available 24 hours a day, 7 days a week—to determine what’s required for each of their patients.

Perform your inquiry using the Service Type, MRI/CAT Scan.

Below is an example of ConnectCenter eligibility search results.

For these services, we require prior authorization for all commercial and Medicare Advantage members:

• Computed Tomagraphy (CT/CTA)
• Magnetic Resonance Imaging (MRI/MRA)
• Nuclear Cardiology Studies
• Breast MRI
• fMRI
• MRS
• Coronary CT/CTA
• CT/PET Fusion
• PET Scans
• Diagnostic and screening colonography

Ordering physicians or clinicians must request authorization before the member receives the test (or before performing services). There are three ways to contact Carelon to request prior authorization:

1. Through a direct link on this site (no additional registration is required). In the eTools tab, go to Carelon. Click the Go Now button.
2. Go directly to the Carelon ProviderPortal (registration is required)
   • Go to www.providerportal.com
   Note: If you’ve already registered for the Carelon ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won’t need to register again.
3. Call Carelon’s Contact Center at 1-866-745-1783
   • Available Monday through Friday, 8 a.m. – 6 p.m. If you leave a voicemail after these hours, Carelon will respond the next business day.

Registration is required for web access. When a new provider joins your group, please make sure that clinician is registered with Carelon.

If you are the contracted provider or facility performing the study:

• Register for Carelon as a servicing provider
• Use Carelon’s website to verify whether a prior authorization number has been issued for the member before rendering the service.

Prior authorization is valid for 60 days from the date issued. If the member does not receive the approved test within 60 days, the ordering provider will need to submit a new request.

You will need the following information to make your request:

• Member’s name, ID number, and date of birth
• Ordering provider’s name and address
• Name of imaging facility where the exam will be performed and the date of service
• Type of service (CPT code optional).
• Reason (indication) for the imaging procedure and/or CPT diagnosis code
• Medical records of pertinent previous studies (labs, X-rays, etc.) and treatments, including their duration. This information is critical to the decision-making. If not included, your request is likely to be denied.
• Member’s symptoms

If you are requesting multiple services, please attach medical necessity notes for each service requested. 

Carelon will issue a prior authorization number, or forward the case to a nurse or physician for review.  The physician reviewer may contact the ordering provider to discuss the case.  Ordering providers may also contact Carelon’s physician reviewer at any time during the process.

Carelon is delegated to conduct individual consideration for certain HTR modalities. Here’s more information about the appeals process for HTR services: