Carelon Behavioral Health appeals: routes, deadlines and criteria

Who is Carelon Behavioral Health, and whom does it manage benefits for?

Carelon Behavioral Health, Inc. is the name, since March 1, 2023, of Beacon Health Options, which Anthem, now Elevance Health, acquired in 2020. Its clients include employer groups, commercial and exchange plans, Medicare Advantage and Medicaid plans and government programs. It also provides utilization management for many Anthem Blue Cross and Blue Shield plans.

Carelon publishes state addenda that override the national handbook where they differ. When documents conflict, the member's benefit plan comes first, then the provider agreement, then the handbook. For Anthem members, Carelon handles utilization management while Anthem handles claims and claim payment disputes; see the Anthem guide.

What are Carelon's appeal levels and deadlines?

Carelon's handbook allows up to 180 calendar days from receipt of the notice for a Level I appeal and 90 days for a Level II appeal where the plan offers one. Standard appeals are decided within 15 calendar days, expedited within 72 hours and retrospective within 30 days, unless the plan, the program or the law says otherwise.

If an administrative denial is in place, it must be resolved before Carelon processes a clinical request. The handbook warns that failing to request an available Carelon appeal on time can stop a provider from challenging the decision later, and that members may not be billed until their appeals are exhausted and they agree in writing. Where the plan provides it, external review or arbitration follows the internal levels.

Clinical or administrative: which Carelon appeal applies?

Look at what the notice decided. A medical-necessity or level-of-care decision is a clinical appeal, started with the number in the adverse determination letter. A non-clinical decision, such as no authorization or late notification, is an administrative appeal, started with the number in that letter. Payment disputes are written claim appeals.

• Clinical: residential or IOP days denied as not medically necessary (CARC 50) and concurrent-review cuts.
• Administrative: no authorization (CARC 197), units over the authorization (CARC 198) or late notification.
• Claim appeal: payment disputes, in writing within 60 days using Carelon's Provider Claims Based Dispute Resolution Request form.
• Provider rights: a participating provider may appeal for the member when the member assigns appeal rights in writing.

How does peer-to-peer review work at Carelon?

Carelon's care manager may arrange a peer-to-peer review with the attending provider before a decision, and only a psychiatrist, or for some levels of care a doctoral-level psychologist, can issue a clinical denial. When a medical-necessity denial is issued without a peer conversation, the notice must offer reconsideration within three business days of receipt.

That three-business-day reconsideration is the only peer-review window the national handbook publishes; state addenda can add their own. After a denial, providers can also appeal and speak with another peer reviewer through the toll-free number for the member's plan. Prepare with the peer-to-peer prep sheet.

Which clinical criteria does Carelon say it uses?

Carelon says its criteria vary with state and contract requirements and benefit coverage. Its handbook applies, in order: CMS coverage criteria for Medicare members, custom state or client criteria including MCG when contracted, the ASAM Criteria for substance use, InterQual Behavioral Health for other levels of care, and Carelon's own criteria as the fallback.

Carelon's national criteria page and handbook do not name LOCUS, CALOCUS-CASII or ECSII; a state or client contract may still require them, so ask which set applied to your case.

How do you get the criteria and the claim file from Carelon?

Carelon's denial notices must say the criteria or rationale used will be provided in writing on request, and its handbook gives provider.inquiry@carelon.com for copies of medical necessity criteria. InterQual access requires an application through Carelon's criteria portal. Carelon describes no claim-file procedure, so ask for the file in writing in the appeal.

Federal parity rules require plans to disclose mental health and substance use medical-necessity criteria on request to participants and contracting providers, and employer plans must provide claim documents free. The criteria request letter covers both.

Where do you submit a Carelon appeal?

Clinical and administrative appeals start with the phone number in the denial letter and can be made verbally, in writing or by fax. Claim appeals go in writing to the address on the provider summary voucher. Carelon's Provider Digital Front Door, including Availity Essentials, ProviderConnect and eServices, supports submitting appeal requests.

Carelon's handbook sets claim timely filing at 90 calendar days from the date of service or discharge, so keep clearinghouse acceptance reports: they are the only answer to a CARC 29 timely-filing denial.

Which denial codes come up on Carelon behavioral health claims?

Carelon claims use the standard reason codes. Medical necessity (50) and denial at authorization (39) usually point to a clinical appeal; authorization absent or exceeded (197, 198) and late filing (29) to an administrative or claim appeal; and provider-type codes (170, 185) to credentialing. Read the remark code with each one.