Preapprovals (preauthorization)
About preapproval reviews
Wellpoint requires preapproval (preauthorization) review for some services for non-Medicare members. Depending on the service, preapproval reviews are performed by:
Carelon Medical Benefits Management
The Provider Reference Sheet lists the services and procedures that require preapproval, what the review requirements are, and who performs each type of review.
To request preapproval
Supporting materials
- Provider Reference Sheet lists all services and procedures that require preapproval review.
Reviews by Carelon Medical Benefits Management (CMBM)
Carelon Medical Benefits Management (CMBM) is a Wellpoint-affiliated company that provides support for the preapproval process. The Provider Reference Sheet lists all services reviewed by CMBM.
Carelon Medical Benefits Management’s web-based provider portal application lets providers submit review requests. Often, the entire review and approval process can be done online. Providers who are already registered for the application do not need to re-register for Wellpoint.
Post-Claim Clinical Appropriateness (PCCA) review
CMBM also handles Post-Claim Clinical Appropriateness (PCCA) reviews for radiology, sleep, genetic testing, and radiation oncology CPT codes. Cases for PCCA review must be more than two business days old, but no more than two years (730 days) old. To initiate a case, you must provide the following information:
- Member information (Name, DOB, Patient HCID#)
- Claim number
- Date of service
- CPT codes
- Diagnosis codes
- Medical records
Supporting materials
Provider Reference Sheet lists all services and procedures that require preapproval review.
Preapprovals for oncology specialty drugs
Preapprovals for Genetic Testing
Cardiac Imaging Preapproval Worksheet
CT/CTA/MRI/MRA Preapproval Worksheet
Myocardial Perfusion Imaging (MPI) or Stress Echocardiography (SE) Preapproval Worksheet
Carelon Medical Benefits Management notices
May 13, 2024 - Medical Oncology and Musculoskeletal Services
April 1, 2024 - Genetic Testing Guidelines
April 1, 2024 – Radiation Oncology
February 1, 2024 and April 1, 2024 – Genetic Testing and Radiology
November 1, 2023 - Virtual Colonoscopy (CT Colongraphy)
April 9, 2023 – Radiation Oncology Clinical Guidelines
Reviews by CarelonRx
CarelonRx reviews certain infused (non-oncology) specialty drugs. For non-Medicare Wellpoint members receiving infusions in a hospital outpatient setting, CarelonRx will perform an expanded review for both the drug’s clinical appropriateness and the level of care/site of service.