If your health plan uses Carelon for utilization management, you may encounter its prior authorization process before accessing certain medications, procedures, or services. Carelon prior authorization is the gatekeeping function performed by Carelon Health, a subsidiary of Elevance Health (formerly Anthem). Understanding how Carelon reviews and approves requests can significantly reduce the time between your doctor’s order and your treatment. Here is what patients and providers need to know.
What Is Carelon and Why Does It Handle Prior Authorization?
Carelon Health is a healthcare services company that provides utilization management, pharmacy benefits, behavioral health services, and clinical decision support for health plans affiliated with Elevance Health. When your insurance plan is administered by Anthem Blue Cross Blue Shield, Empire BlueCross BlueShield, or another Elevance Health subsidiary, Carelon often handles the prior authorization process for medical services and certain medications.
Carelon prior authorization applies to a range of services including advanced imaging (MRI, CT, PET scans), specialty medications, outpatient surgeries, inpatient admissions, genetic testing, and certain durable medical equipment. The specific services requiring authorization depend on your plan design — not every Elevance-affiliated plan uses Carelon for the same categories.
Carelon’s stated goal is to ensure that services are medically necessary and consistent with evidence-based clinical guidelines. In practice, this means your doctor must demonstrate that a requested service meets specific criteria before the plan agrees to pay for it.
How to Submit a Carelon Prior Authorization Request
Prior authorization requests are submitted by your healthcare provider, not by you as the patient. However, understanding the process helps you advocate for timely resolution.
Online submission (preferred): Providers submit requests through the Carelon provider portal at availity.com or the Carelon-specific portal. Online submission is the fastest method and allows real-time status tracking. The portal guides the provider through required fields, including diagnosis codes, clinical rationale, and supporting documentation.
Phone submission: Providers can call Carelon’s prior authorization line. The phone number varies by plan and service type — imaging, pharmacy, behavioral health, and medical/surgical each have dedicated lines. Your provider’s office should have the correct number for your plan. General inquiries can start at the number on the back of your member ID card.
Fax submission: Some providers still submit PA requests via fax, particularly for complex cases requiring extensive documentation. Fax numbers are available through the Carelon provider portal or plan-specific resources.
Regardless of the method, the submission must include your diagnosis and relevant clinical history, the specific service or medication being requested, the clinical rationale for why it is medically necessary, any prior treatments tried and the reasons they were insufficient, and supporting documentation such as lab results, imaging reports, or specialist notes.
What Documentation Strengthens a Carelon PA Request
Incomplete submissions are the most common cause of delays and denials. Providers who submit thorough documentation from the start see faster approvals. Key elements include:
Detailed clinical notes: Not just the diagnosis — include the severity, duration, and functional impact of the condition. For a prior authorization for advanced imaging, explain what the physical exam and initial workup revealed and why imaging is the logical next step.
Prior treatment documentation: If the requested service is a second-line treatment, document exactly which first-line options were tried, for how long, at what dosage, and why they failed. Vague statements like “patient did not respond” are less effective than specific clinical data showing inadequate response.
Evidence-based guidelines: Reference professional society guidelines or peer-reviewed literature supporting the request. If the American College of Cardiology recommends cardiac MRI for a specific clinical scenario, citing that guideline strengthens the case.
Peer-to-peer readiness: For complex or non-standard requests, Carelon may schedule a peer-to-peer review — a phone call between the requesting physician and a Carelon medical director. Being prepared for this conversation with organized clinical data improves outcomes significantly.
Decision Timelines
Carelon prior authorization decisions follow timelines set by state and federal regulations, as well as plan-specific requirements:
Standard requests: Typically decided within 2 to 5 business days. For Medicare Advantage plans, CMS requires a decision within 7 calendar days for standard pre-service requests.
Urgent/expedited requests: When a delay could seriously jeopardize the patient’s health, Carelon processes urgent requests within 24 to 72 hours. The provider must indicate urgency at the time of submission and provide clinical justification for the expedited timeline.
Retrospective reviews: For services already provided (typically emergency situations), retrospective PA reviews are completed within 30 days.
If Carelon does not issue a decision within the required timeframe, the request may be considered approved by default, depending on state law and plan terms. Track the status through the provider portal or by calling the PA line.
What Happens If Carelon Denies Your Request
A denial triggers a formal notification letter explaining the reason and citing the clinical criteria that were not met. You and your provider both receive this notice. From there, you have several options:
Peer-to-peer review: Before filing a formal appeal, your doctor can request a peer-to-peer conversation with the Carelon medical director who made the denial decision. This is an opportunity to present additional clinical context and potentially reverse the denial without a formal appeal.
First-level appeal: Submit a written appeal within the timeframe specified in the denial letter (typically 30 to 60 days). Include additional clinical documentation, updated test results, and a detailed letter of medical necessity from your treating physician. According to industry data, a meaningful share of first-level appeals result in overturn of the original denial.
External review: If the internal appeal is denied, most plans offer an external review by an independent review organization (IRO). The IRO evaluates the case without any affiliation to Carelon or your insurance plan. External review decisions are binding on the plan in many states.
State insurance department complaint: If you believe the denial violates state insurance regulations, you can file a complaint with your state’s department of insurance. This does not replace the appeal process but can prompt regulatory scrutiny of the denial.
Carelon Prior Authorization for Specific Services
Advanced imaging: Carelon uses evidence-based guidelines to evaluate requests for MRI, CT, PET, and nuclear medicine studies. Common approval criteria include failure of conservative treatment, red-flag symptoms warranting urgent evaluation, and clinical findings consistent with guideline-recommended imaging.
Specialty medications: For high-cost drugs, Carelon coordinates with the plan’s PBM to review PA requests. This includes biologics, oncology drugs, and other specialty medications typically dispensed through specialty pharmacies. Documentation requirements are extensive, often including genetic testing results, pathology reports, or disease activity scores.
Behavioral health: Carelon Behavioral Health handles PA for inpatient psychiatric admissions, residential treatment, intensive outpatient programs, and certain outpatient services. Clinical criteria focus on severity of symptoms, risk of harm, and appropriateness of the requested level of care.
Surgical procedures: Elective surgeries, particularly those with conservative treatment alternatives (like joint replacement or bariatric surgery), frequently require PA through Carelon. Documentation should demonstrate that non-surgical options have been exhausted and that the patient meets clinical criteria.
Frequently Asked Questions
How do I check the status of a Carelon prior authorization?
Providers can check status through the Carelon online portal. As a patient, call the member services number on your insurance card and ask for PA status. You can also ask your doctor’s office to check on your behalf through the provider portal.
Does Carelon handle prior authorization for all Anthem plans?
Carelon handles utilization management for many Elevance Health-affiliated plans, but not all services across all plans. Some plans use different vendors for specific service categories. Check your plan documents or call member services to confirm which entity handles PA for your specific service.
Can I submit a prior authorization request myself?
No. Prior authorization must be submitted by a licensed healthcare provider. However, you can and should follow up on the status, ensure your provider has submitted the request promptly, and provide any patient-facing documentation (like a medication history) that supports the request.
What if I need emergency care — is prior authorization required?
Emergency services do not require prior authorization. Federal law (the Emergency Medical Treatment and Labor Act) and plan terms ensure that emergency care is covered regardless of PA status. However, follow-up care after the emergency may require retrospective or prospective authorization.
Making the Process Work for You
The Carelon prior authorization process is bureaucratic, but it does not have to derail your care. Ask your doctor to check PA requirements before ordering a service. Ensure the initial submission includes complete, evidence-based documentation. Follow up within 48 hours to confirm receipt and processing. If denied, use the peer-to-peer option before escalating to a formal appeal.
For broader context on prior authorization across different insurers and PBMs, see our guides to prior authorization for medication and Medicare prior authorization. For the policy perspective, visit our healthcare policy guide.