Surgical UM and Site of Care programs available to ASO plans effective January 1, 2026

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) previously announced that Carelon Medical Benefits Management (Carelon) would administer new surgical utilization management (UM) and site of care (SOC) programs.

These programs will be expanded to include Administrative Services Only (ASO) groups that elect this program. Providers may begin contacting Carelon to obtain prior authorization for surgeries and pain treatment on December 18, 2025, for dates of service on or after January 1, 2026.

Surgical UM: For services that are scheduled to begin on or after January 1,2026, all providers must contact Carelon to obtain pre-service review for the following non-emergency modalities:

• Upper GI endoscopy (EGD)

Surgical site of care (SOC): For services that are scheduled to begin on or after January 1, 2026, all providers must contact Carelon to obtain pre-service review for certain minor surgical procedures, including EGD, when the requested location is the hospital-based outpatient setting. When medical necessity criteria for these minor surgical procedures in a hospital-based outpatient setting are not met, an alternative less-intensive site of care should be utilized, such as an ambulatory surgery center (ASC) or provider office. Carelon is available for a peer-to-peer discussion before or after the decision, in the event your office wishes to speak with Carelon.

Please note, for digestive surgical procedures, Carelon currently performs medical necessity review of the upper endoscopy procedures, which will continue to be a requirement for these services, in addition to the site of care review when the hospital-based outpatient setting is requested. For all other included minor surgical procedure codes, no prior authorization is required if the requested location is ASC or provider office.

The surgical site of care review applies only to select procedures of the below systems when performed in an outpatient hospital setting:

• Digestive
• Eye, ocular adnexa and ear
• Urinary

View a complete list of procedures subject to site of care review.

How to submit a request for review

Starting December 18, 2025, providers can begin submitting requests for review or verify order numbers using one of the following methods:

Online

Access Carelon’s portal through Blue e, which is available 24/7, fully interactive, and processes requests in real-time using clinical criteria.

By phone

Call Carelon Medical Benefits Management toll-free at 866-455-8414 Monday through Friday between 8 AM–6 PM EST.

Resources

Online

For resources to help your practice get started with the Surgical Program, go to the Carelon Surgical Website.

To learn more about Carelon, please visit www.carelon.com.