New Effective Date for Diagnostic Imaging Management Program for Experience Health Members

June 12, 2024, Update: The below communication was posted May 1, 2024, regarding implementation of the Diagnostic Imaging Management Program, administered by Carelon, for Experience Health members effective July 1, 2024.

The effective date for this program has moved from July 1, 2024, to July 15, 2024. Under the new effective date, providers should contact Carelon beginning July 1, 2024, to request prior review for diagnostic imaging services occurring on or after July 15, 2024.

If you have other colleagues in your practice who will be submitting prior authorization requests for diagnostic imaging services, we encourage you to share this updated notice with them.

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Effective July 1, 2024, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will implement the Diagnostic Imaging Management (DIM) program for Experience Health members.

DIM is part of Blue Cross NC’s existing prior review program that requires prior approval of certain high-tech imaging procedures. This program seeks to manage costs while helping to ensure that members get the right test, at the right time. Carelon Medical Benefits Management (Carelon) administers the DIM program.

Beginning June 17, 2024, providers should contact Carelon to request prior review for diagnostic imaging services occurring on or after July 1, 2024.

The following types of imaging services require prior approval:

• MRI - Magnetic Resonance Imaging
• MRA - Magnetic Resonance Angiogram
• MRS - Magnetic Resonance Spectroscopy
• CT - Computerized Tomography
• CTA - Computerized Tomography Angiogram
• Nuclear Medicine
• PET - Positron Emission Tomography

The Diagnostic Imaging Prior Review Code List can be found on the Prior Plan Approval page on the Blue Cross NC website.

Enhanced Review Program

Blue Cross NC will also partner with Carelon to add the Enhanced Review program to the Medicare DIM program. This program will add a review to imaging services using clinical appropriateness criteria to help ensure that care aligns with established, evidence-based medicine. Carelon clinical guidelines are applied to the review and in select circumstances, additional medical records may be requested. By limiting records review to requests that are less likely to be appropriate, the effort required for prior authorization will be reduced.

Providers are strongly encouraged to verify that prior authorization has been obtained before scheduling and performing services. Submitting medical records is not necessary unless requested by Carelon.

Prior authorization requests may be submitted to Carelon using one of the following methods:

Online

Get fast, convenient online service via the Carelon Provider Portal (registration required). Provider Portal is available 24 hrs./day, 7 days/week. Visit the Carelon Provider Portal to begin.

By Phone

Call Carelon toll-free at 866-455-8414

Hours: Monday – Friday 8:00 – 5:00 PM (EDT)

If you have other colleagues in your practice who will be submitting prior authorization requests, we encourage you to share this notice with them.