The RQI program does not apply to Medicare primary members with BCBSTX Medicare supplement.Facilities can now obtain an RQI from Carelon on behalf of the ordering physician.When an RQI is needed, health care providers must contact Carelon before ordering or scheduling the following outpatient diagnostic imaging services when performed in a physician's/professional provider's office, the outpatient department of a hospital or a freestanding imaging center:Ĭarelon RQI Procedure Codes for this program Payment may be denied if procedures are performed without authorization and health care providers may not bill the patient.Ĭarelon Radiology Quality Initiative ProgramĬarelon provides clinical appropriateness review and education for outpatient high-tech diagnostic imaging services through their prenotification Radiology Quality Initiative (RQI) program for some Blue Choice PPO SM members.For joint and spine surgery prior authorizations, if an outpatient or inpatient facility stay is being requested, providers will contact Carelon first for medical necessity determination, then contact BCBSTX for final determination of length of stay & the level of care.Ordering physicians or servicing providers (facilities) may submit prior authorization requests.Services can vary depending on the patient benefits. Providers need to determine if prior authorization is required through Carelon before rendering services.Joint and Spine Surgery, and Pain Management.Outpatient Services Impactedįor services noted below select the category on the Carelon website. With Carelon administering prior authorizations, we can optimize our programs, further ensuring that care aligns with established evidence-based medicine. Employees Retirement System of Texas (ERS) participants.Teacher Retirement System of Texas (TRS) participants.Blue Premier SM and Blue Premier Access SM.

Carelon Prior Authorization ProgramĬarelon provides required prior authorization review and approvals for select outpatient services. Prenotification Radiology Quality Initiative (RQI) program for outpatient high-tech diagnostic imaging servicesīe sure to verify eligibility and benefits and check prior authorization/prenotification requirements through Availity ® or your preferred vendor to determine if a prior authorization or an RQI is needed for the patient depending on their benefit plan.Prior authorization and post service medical necessity review for certain outpatient services.If you choose to do business with this business, please let the business know that you contacted BBB for a BBB Business Profile.Īs a matter of policy, BBB does not endorse any product, service or business.Carelon is a specialty health benefits company that works with leading insurers to improve health care quality and manage costs for today’s most complex and prevalent clinical guidelines, tests and treatments, helping to promote care that is appropriate, safe and affordable. BBB Business Profiles are subject to change at any time. When considering complaint information, please take into account the company's size and volume of transactions, and understand that the nature of complaints and a firm's responses to them are often more important than the number of complaints.īBB Business Profiles generally cover a three-year reporting period. However, BBB does not verify the accuracy of information provided by third parties, and does not guarantee the accuracy of any information in Business Profiles. BBB asks third parties who publish complaints, reviews and/or responses on this website to affirm that the information provided is accurate. BBB Business Profiles may not be reproduced for sales or promotional purposes.īBB Business Profiles are provided solely to assist you in exercising your own best judgment.

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