Carelon Behavioral Health is not an insurer. It is a third-party administrator and utilization-review agent that runs the behavioral health benefit for somebody else’s plan — employer groups, commercial and exchange health plans, Medicare Advantage plans, managed Medicaid plans, and state and local government programs. That is its own description of itself in its provider handbook, and it is the whole reason this page exists: a family hands you an Empire Plan card issued by New York State, or an EmblemHealth card, and the ABA authorization does not go to the name on the front of the card. It goes to Carelon.
Intake teams lose days to this. They verify medical benefits with the plan, get a clean answer, book the assessment — and only when the claim denies do they learn that behavioral health was carved out to a separate administrator with its own network, its own forms, its own portal and its own 90-day filing clock. The good news is that Carelon publishes a genuinely national ABA authorization form and a national treatment-report standard, so once you know Carelon is in play, the paperwork is knowable in advance.
The signal is almost never the front of the card. It is the back — and the fact that the behavioral health phone number is different from the medical one.[8][10][1]
The Empire Plan is the cleanest illustration in the country. New York State Civil Service names three different administrators for one plan: UnitedHealthcare Insurance Company of New York runs the Medical/Surgical Program, Anthem Blue Cross runs the Hospital Program, and Carelon Behavioral Health, Inc. runs the Mental Health and Substance Use Program. All three sit behind a single number, 1-877-7-NYSHIP, and you reach Carelon by pressing 3. A family says “we have UnitedHealthcare” and they are not wrong — but the ABA authorization is Carelon’s. Applied behavior analysis providers and ABA agencies are named practitioner types in the Empire Plan MHSU program, so this is not a coverage question; it is a routing question.[8][10][1]
EmblemHealth works the same way and says so in writing: behavioral health runs through two Carelon-administered programs — the EmblemHealth Behavioral Management Program (BMP) for plans underwritten by EmblemHealth Plan, Inc., and the Emblem Behavioral Health Services Program (EBHSP) for plans underwritten by HIP or EmblemHealth Insurance Company — and the manual tells providers to look at the back of the member’s ID card to find out which one applies. Carelon “manages all behavioral health covered services including utilization management and case management,” and behavioral health claims go to Carelon through ProviderConnect or a clearinghouse, not to EmblemHealth.[8][10][1]
A behavioral health line that differs from the medical member-services line is the single most reliable tell. On the Empire Plan it is option 3 of 1-877-7-NYSHIP; on an EmblemHealth card it is the BMP or EBHSP line.[8][10][1]
“Behavioral Management Program,” “Behavioral Health Services Program,” “Mental Health and Substance Use Program” — named programs on the card almost always mean a carve-out administrator.[8][10][1]
A 271 response from the medical plan that returns medical, surgical and pharmacy benefits but is silent or non-specific on mental health service types is a prompt to ask who administers behavioral health — not evidence that ABA is uncovered.[8][10][1]
Carelon’s provider handbook lists state/plan-specific supplements for Anthem Blue Cross and Blue Shield in Colorado, Connecticut, Kentucky, Maine, Missouri, New Hampshire and Virginia, plus Wellpoint Florida and Wellpoint New Jersey and Virginia Anthem HealthKeepers Plus. If your family’s plan is on that list, assume Carelon.[8][10][1]
Carelon was Beacon Health Options. Its own documents say so: the autism provider manual it hosts for San Francisco Health Plan opens “Today we are Carelon Behavioral Health. We are working on updating all documents, but some historic references to Beacon may remain.” A Beacon reference on a plan document is a Carelon reference.[8][10][1]
Carelon runs what it calls a Provider Digital Front Door built on three surfaces, and the Availity-versus-own-portal question has a precise answer: it is both, linked. Availity Essentials is the multi-payer front end for eligibility, benefits, claim detail, prior-authorization submission and claim status. ProviderConnect and eServices are Carelon’s own portals, and which one you use depends on the client plan — the handbook is explicit that “depending on your plan, you may need to use both.” ProviderConnect handles authorization and certification requests for all levels of care, concurrent review and discharge reporting, authorization letters and provider summary vouchers; eServices handles real-time claim status, EOB printing, authorization requests and units-used checks.[1][10]
Set up single sign-on once and stop guessing: register a ProviderConnect and/or eServices account, register an Availity account, then link them in the Availity payer space under organization administration. After that the Carelon portals open from Availity.[1][10]
The phone numbers that matter at intake: the National Provider Service Line is 800-397-1630 (Mon–Fri, 8 a.m.–8 p.m. ET) for network, demographic and general provider questions; general claim inquiries are 800-888-3944; ProviderConnect direct-submission technical support is 888-247-9311. EDI claims go through Availity as Carelon’s clearinghouse partner (Availity customer service 800-282-4548).[1][10]
One thing Carelon deliberately does not publish nationally: the payer ID. The handbook says to find the correct payer ID in the client- and state-specific guidelines on its website, or to search Availity’s payer list. Because Carelon is administering many different sponsors’ benefits, behavioral health claims for two families both “with Carelon” can carry different payer IDs. Capture the plan name at intake, not just “Carelon.”[1][10]
Carelon publishes two ABA documents in the global (national) section of its forms library, and between them they define the whole submission. The ABA Authorization Request form, effective 1/1/2026, covers initial assessment, initial treatment and concurrent requests on a single sheet — so the assessment itself is an authorized event, not a free first step. It asks for the patient’s employer/benefit plan by name (another reminder that Carelon is administering somebody else’s benefit), the supervising BCBA/LBA/LABA with certification number, state, NPI and Carelon provider ID, the group TIN, and the program setting: home, facility/clinic, school or other.[2][3]
Every code is requested in 15-minute units (four units to the hour), with the form itself carrying the limits and the conditions:[2][3]
Administered by a physician/QHP. Up to 32 units (8 hours) for the initial and up to 32 units for a reassessment with clinical justification.[2][3]
Technician-administered (0362T with two or more technicians and the QHP on-site for destructive behavior). Both explicitly require clinical justification.[2][3]
By a technician under the direction of the physician/QHP, “receiving 1 hour of supervision for every 5 to 10 hours of direct treatment.” Requested as hours per week plus units.[2][3]
By the physician/QHP; 97155 may be used for direction of technician (supervision) face-to-face. Requested as hours per day and days per week.[2][3]
The ABA Provider Treatment Report Guidelines are a fourteen-section specification for the initial packet and a nine-section specification for the concurrent report. Several requirements are the kind that get a resubmission rather than an approval if intake did not gather the inputs:[3]
The report must carry the diagnosis with its date and the name and title of the professional who made it, the date(s) of the original assessment, and the name, title and credential of the assessor — plus the supervising BCBA, with the date of change and the prior supervisor if the case changed hands.[3]
A minimum of two direct observations of the member is recommended, alongside named indirect sources (caregiver interview, records reviewed such as the IEP and prior ABA reports).[3]
Objectives “should neither be educational in nature nor overlap IEP objectives,” and any that do require written justification. Get the IEP at intake, and read it before you write goals.[3]
The report asks directly whether you have communicated with the psychotropic prescriber, with the PCP, and with other behavioral health providers — and whether the communication or the family’s declination was documented. Releases signed at intake are the difference between answering yes and answering no.[3]
All progress reports are due at minimum two weeks before, and no more than 30 days before, the authorization end date. Graphed per-goal data over the authorization period is mandatory, and data may not be aggregated or averaged by month or quarter unless the goal was written that way.[3]
The summary must break the request into CPT code, description, total hours, hours per week, and the location where services will be delivered.[3]
The biggest structural difference: there is no single Carelon ABA medical-necessity policy to read the way you would read a carrier’s clinical policy bulletin. Carelon’s Corporate Quality Medical Management Committee “adopts, reviews, revises, and approves Medical Necessity Criteria per client and regulatory requirements,” and the criteria vary by state, contract and member benefit. Its own selection order is: CMS NCDs/LCDs for Medicare members first, then custom client criteria, then ASAM for substance use, then InterQual Behavioral Health, and only if none of those apply does Carelon’s national criteria set govern. In practice that means the right question on a benefits call is not “what are Carelon’s ABA criteria” but “which criteria set applies to this client, and where is it published.”[4][5][1]
Where a client criteria set does exist for ABA, it can be very specific. Carelon’s Massachusetts criteria (updated 4/29/2026) admit ABA for members under 21 with a confirmed ASD diagnosis made by a licensed physician, APRN, PA or psychologist experienced in autism, or with a Down syndrome diagnosis confirmed by genetic testing; they authorize an initial assessment first and then require up to 12 hours of direct and indirect assessment within 45 calendar days to produce the initial treatment plan; and they require at least two direct observations, one of them in the home or a naturally occurring community setting, plus formal assessment data from three categories — a validated skill-based or curriculum tool, a standardized treatment-impact measure, and a family/caregiver impact measure. That is a Massachusetts client standard, not a national one; do not carry it to another Carelon plan.[4][5][1]
Second difference: network membership does not transfer. Contracting with the health plan does not put you in the Carelon network, and Carelon maintains its own rostering machinery — including a distinct “Roster for ABA Paraprofessional Provider” form alongside its group, facility and supervised-clinician-group rosters. Third: the clock is Carelon’s. Unless the provider agreement says otherwise, claims must be filed within 90 calendar days of the date of service, and claims that do not match the authorization can be delayed on that basis alone.[4][5][1]
Carelon also runs several public-sector ABA programs that already have their own guides in this directory — Maryland’s Medicaid behavioral health ASO (see our Maryland Medicaid guide), the Massachusetts Behavioral Health Partnership (MBHP), Wellpoint New Jersey and Simply Healthcare in Florida. The commercial carve-out described here shares the portal and the handbook with those programs, but not the clinical criteria or the fee schedule.[4][5][1]
The clinical policy above is national, but three state-level layers change what a family's card actually buys: the state autism mandate (what fully-insured plans must cover), the carrier's state Medicaid plans (which follow the state Medicaid rules, not this commercial policy), and plan funding type (self-funded ERISA plans can carve benefits differently). Here's the picture in the states we cover:
Fully-insured Carelon Behavioral Health plans issued in Georgia sit under the state mandate above. State Medicaid baseline: Georgia Medicaid guide →
Fully-insured Carelon Behavioral Health plans issued in North Carolina sit under the state mandate above. State Medicaid baseline: North Carolina Medicaid guide →
Fully-insured Carelon Behavioral Health plans issued in Indiana sit under the state mandate above. State Medicaid baseline: Indiana Medicaid (IHCP) guide →
Fully-insured Carelon Behavioral Health plans issued in Virginia sit under the state mandate above. State Medicaid baseline: Virginia Medicaid (DMAS) guide →
Fully-insured Carelon Behavioral Health plans issued in Tennessee sit under the state mandate above. State Medicaid baseline: TennCare (Tennessee Medicaid) guide →
Fully-insured Carelon Behavioral Health plans issued in Ohio sit under the state mandate above. State Medicaid baseline: Ohio Medicaid guide →
Fully-insured Carelon Behavioral Health plans issued in New Jersey sit under the state mandate above. State Medicaid baseline: NJ FamilyCare (New Jersey Medicaid) guide →
Fully-insured Carelon Behavioral Health plans issued in Maryland sit under the state mandate above. State Medicaid baseline: Maryland Medicaid (Medical Assistance) guide →
Fully-insured Carelon Behavioral Health plans issued in Colorado sit under the state mandate above. State Medicaid baseline: Health First Colorado (Colorado Medicaid) guide →
Fully-insured Carelon Behavioral Health plans issued in Utah sit under the state mandate above. State Medicaid baseline: Utah Medicaid guide →
Fully-insured Carelon Behavioral Health plans issued in Arizona sit under the state mandate above. State Medicaid baseline: AHCCCS (Arizona Medicaid) guide →
Fully-insured Carelon Behavioral Health plans issued in New York sit under the state mandate above. State Medicaid baseline: New York Medicaid (NYS DOH / eMedNY) guide →
Fully-insured Carelon Behavioral Health plans issued in New Mexico sit under the state mandate above. State Medicaid baseline: New Mexico Medicaid (Turquoise Care) guide →
Fully-insured Carelon Behavioral Health plans issued in Missouri sit under the state mandate above. State Medicaid baseline: MO HealthNet (Missouri Medicaid) guide →
Fully-insured Carelon Behavioral Health plans issued in Texas sit under the state mandate above. State Medicaid baseline: Texas Medicaid (THSteps-CCP) guide →
Fully-insured Carelon Behavioral Health plans issued in Massachusetts sit under the state mandate above. For Medicaid members, Carelon Behavioral Health operates Massachusetts Behavioral Health Partnership (MBHP) — covered by its own guide, not this one. State Medicaid baseline: MassHealth (Massachusetts Medicaid) guide →
Fully-insured Carelon Behavioral Health plans issued in Florida sit under the state mandate above. State Medicaid baseline: Florida Medicaid — Behavior Analysis Services (AHCA) guide →
Fully-insured Carelon Behavioral Health plans issued in Kansas sit under the state mandate above. State Medicaid baseline: KanCare (Kansas Medicaid) guide →
Fully-insured Carelon Behavioral Health plans issued in Nebraska sit under the state mandate above. State Medicaid baseline: Nebraska Medicaid (Heritage Health) guide →
Fully-insured Carelon Behavioral Health plans issued in Idaho sit under the state mandate above. State Medicaid baseline: Idaho Medicaid guide →
Fully-insured Carelon Behavioral Health plans issued in Iowa sit under the state mandate above. State Medicaid baseline: Iowa Medicaid (IA Health Link) guide →
Fully-insured Carelon Behavioral Health plans issued in Oklahoma sit under the state mandate above. State Medicaid baseline: Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide →
Fully-insured Carelon Behavioral Health plans issued in Michigan sit under the state mandate above. State Medicaid baseline: Michigan Medicaid guide →
Fully-insured Carelon Behavioral Health plans issued in Hawaii sit under the state mandate above. State Medicaid baseline: Hawaii Medicaid (Med-QUEST / QUEST Integration) guide →
Fully-insured Carelon Behavioral Health plans issued in California sit under the state mandate above. State Medicaid baseline: Medi-Cal (California Medicaid) guide →
Fully-insured Carelon Behavioral Health plans issued in Pennsylvania sit under the state mandate above. State Medicaid baseline: Pennsylvania Medicaid (Medical Assistance) guide →
The questions that decide whether a family can start with Carelon Behavioral Health, and what they have to bring. Each maps onto something intake should ask on the first call.
What Carelon requires is an authorization rather than a referral, and the assessment is inside it: the national ABA Authorization Request form (effective 1/1/2026) carries an “Initial Assessment” request type alongside “Initial Treatment” and every “Concurrent Request,” so the assessment is an authorized event, not a free first step. The form asks for the patient’s employer/benefit plan by name, the supervising BCBA/LBA/LABA with certification number, state, NPI and Carelon provider ID, the group TIN, and the program setting. Network membership does not transfer from the health plan — contracting with the insurer does not put you in the Carelon network. Claims must be filed within 90 calendar days of the date of service unless the provider agreement says otherwise.[2][1]
Carelon does not set the payment order itself — "Coordination of benefits amongst different sources of coverage (payers) is governed by the terms of the member’s benefit plan and applicable state and/or federal laws, rules and/or regulations" — but it fixes what the provider must do. Ask at intake whether the child has coverage from more than one source and pass it to Carelon; Carelon "may administer both primary and secondary benefit plans of a given member," and reporting "all pertinent employer and other insurance information" avoids a duplicate review. Get the authorization even when Carelon is secondary: its authorization procedures apply "in instances where the member benefit plan administered by Carelon is primary and instances where the member benefit plan administered by Carelon is secondary," and "Authorization, certification or notification requirements under the member’s benefit plan still apply in coordination of benefits situations." Bill Carelon second with the primary payer's EOB — uploaded in ProviderConnect or Availity, mailed separately with EDI or paper claims — and the services on the claim "should match the services included in the primary payer EOB." The 90-day filing clock then runs "from date of determination by the primary payer," and primary plus secondary payment never exceeds the provider-agreement rate. Some plans make the member re-report other coverage (e.g. annually) and deny claims until they do.[1]
Ask the plan: Which plan is primary for this child (two parents' plans, Medicaid, TRICARE) is decided by the client plan's COB terms — confirm on the National Provider Service Line 800-397-1630.
No national age limit exists, because there is no national ABA medical-necessity policy to carry one. Carelon’s Corporate Quality Medical Management Committee “adopts, reviews, revises, and approves Medical Necessity Criteria per client and regulatory requirements,” and criteria vary by state, contract and member benefit. Where a client set does exist it can be specific: Carelon’s Massachusetts criteria admit ABA for members under 21. Do not carry a client’s age band to another Carelon plan.[4][5][1]
Ask the plan: Ask which criteria set applies to this client plan and where it is published — National Provider Service Line 800-397-1630, or the client-specific guidelines in Carelon’s forms-and-guides library. “What are Carelon’s ABA criteria” is the wrong question; “which criteria set governs this client” is the right one.
No national recency rule. What the ABA Provider Treatment Report Guidelines require instead is provenance: the report must carry the diagnosis with its date and the name and title of the professional who made it, plus the date(s) of the original assessment and the name, title and credential of the assessor. So the diagnosis date is mandatory reporting data even though no expiry attaches to it nationally. Concurrent reports have their own window — due at minimum two weeks before, and no more than 30 days before, the authorization end date.[3][4]
Ask the plan: The governing client criteria set — National Provider Service Line 800-397-1630. A client standard can be much tighter than the national default.
Set per client, not nationally. Carelon’s national ABA treatment-report guidelines are written for members with an autism spectrum diagnosis and require the report to name the professional who made it and their title, but they do not define which credentials qualify. A client set can: Carelon’s Massachusetts criteria admit ABA for members under 21 with a confirmed ASD diagnosis “made by a licensed physician, APRN, PA or psychologist experienced in autism,” or with a Down syndrome diagnosis confirmed by genetic testing. That is a Massachusetts client standard and must not be carried to another Carelon plan.[3][5][4]
Ask the plan: Ask which criteria set governs this client plan and where it is published — National Provider Service Line 800-397-1630.
No instrument is required nationally. The treatment report requires a minimum of two direct observations of the member alongside named indirect sources — caregiver interview, and records reviewed such as the IEP and prior ABA reports — and requires graphed per-goal data over the authorization period, which may not be aggregated or averaged by month or quarter unless the goal was written that way. A client set can demand far more: Carelon’s Massachusetts criteria require at least two direct observations with one in the home or a naturally occurring community setting, plus formal assessment data from three categories — a validated skill-based or curriculum tool, a standardized treatment-impact measure, and a family/caregiver impact measure.[3][5]
Ask the plan: The governing client criteria set — National Provider Service Line 800-397-1630, or the client supplement in the forms-and-guides library.
Carelon publishes no national ABA telehealth code list. The treatment record does have to declare it: every entry must record the modality — office-based or telehealth, and which telehealth modality — alongside the responsible clinician’s name, professional degree and identification number and the session start and stop times. Whether a given ABA code is payable remotely is a client-benefit and client-criteria question.[1][4]
Ask the plan: National Provider Service Line 800-397-1630 with the employer/benefit plan name in hand — ask which ABA codes this client pays by telehealth and whether the authorization must say so.
Carelon publishes a default decision clock, expressly "Subject to any client, government-sponsored health benefit program, and/or benefit plan specific requirements." Its Standard Determination Time Frames chart: a prospective (pre-service) urgent request is decided "Within 72 hours"; prospective non-urgent "Within 15 calendar days (7 for contracts governed by CMS)"; a concurrent urgent request made more than 24 hours before the authorization expires "Within 24 hours," inside 24 hours "Within 72 hours"; a concurrent non-urgent request "Reverts to Prospective" (72 hours / 15 calendar days, 7 under CMS contracts); retrospective within 30 calendar days. The chart does not say whether the clock starts at receipt or at a complete request. For ABA the lead time that actually binds is the treatment report's: "All progress reports are due, at minimum, two weeks prior to, and no more than 30 days, to the authorization end date" — calendar the concurrent request 30 days before expiry and never later than 14. Underneath the chart sit the federal floors: an employer (ERISA) group health plan must decide a pre-service claim "not later than 15 days after receipt of the claim by the plan" and an urgent one within 72 hours; a Medicaid managed-care client is held to 7 calendar days standard / 72 hours expedited for rating periods starting on or after 1/1/2026 (42 CFR 438.210(d)). A shorter state-law or client-contract clock wins.[1][3][11][12]
Ask the plan: National Provider Service Line 800-397-1630 with the employer/benefit plan name in hand — ask whether this client contract or the state's utilization-review law sets a shorter decision clock than the handbook chart, and whether it runs from receipt or from a complete request.
Coverage decides whether Carelon Behavioral Health pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
97153 is delivered by a technician under the direction of the physician/QHP “receiving 1 hour of supervision for every 5 to 10 hours of direct treatment.” 97155 may be used for direction of technician (supervision) face-to-face with one patient; 0362T and 0373T require the physician/QHP on-site with two or more technicians.[2]
The ABA treatment report must be signed with the title and credential of its author and of the supervising BCBA if different; a parent signature is recommended. In the treatment record itself, every entry must be dated and carry the responsible clinician’s name, professional degree and relevant identification number, the modality (office-based or telehealth, and which telehealth modality), and the session start and stop times.[3][1]
Same-day pairing is governed by the client plan, not by one national rule. Carelon’s San Francisco Health Plan autism manual states the standard rule that only one service code is paid per day, with named exceptions for a patient seen by two different providers on the same day (e.g., BCBA and ABA tutor) and for ABA therapy plus BCBA supervision on the same day.[7]
Ask the plan: Ask the Carelon National Provider Service Line (800-397-1630) for the same-day billing rule under the specific client plan, and check that client’s supplement in the forms-and-guides library.
One national cap, and the rest is the client plan. The ABA Authorization Request form itself caps 97151 at up to 32 units (8 hours) for the initial assessment, with up to 32 more for a reassessment supported by clinical justification, and flags 97152 and 0362T as requiring clinical justification. Everything is requested in 15-minute units — 97153 as hours per week plus units, 97155 and 0373T as hours per day and days per week — so the form itself imposes a shape on the request even where it imposes no ceiling. Carelon publishes no national per-day MUE table; per-day and per-week ceilings beyond 97151 are set in the client plan’s benefit and criteria.[2][4]
Ask the plan: The client plan’s supplement in Carelon’s forms-and-guides library, or the National Provider Service Line at 800-397-1630 — ask which criteria set governs this client and whether it carries per-day unit ceilings.
The national ABA Authorization Request form asks you to declare the program setting as home, facility/clinic, school or other, and the treatment report requires the delivery location per code. Whether a declared setting is payable is a client-benefit question — and treatment-plan objectives “should neither be educational in nature nor overlap IEP objectives” without written justification.[2][3]
Ask the plan: Confirm payable settings against the client plan’s benefit document and the applicable state/client criteria before scheduling school-based hours.
Carelon’s national ABA form is built around a named supervising BCBA/LBA/LABA with certification number, NPI and Carelon provider ID, plus the group TIN, and Carelon rosters ABA paraprofessionals separately through a dedicated “Roster for ABA Paraprofessional Provider” form. The handbook’s general claims rule is that participating providers should not submit claims in their own name for services provided by another clinician; how that applies to technician-delivered 97153 is set in the client contract.[2][1]
Ask the plan: Confirm the rendering-vs-billing NPI convention with your Carelon network manager or the National Provider Service Line (800-397-1630) for the specific client plan.
No. Its provider handbook describes it as licensed in numerous states as a third-party administrator and/or utilization-review agent of behavioral health services, managing benefits under contract for employer groups, commercial and exchange health plans, Medicare Advantage and managed Medicaid plans, and government programs. Some affiliates are licensed health plans in specific states, but the entity you deal with for ABA is usually the administrator, not the insurer.
Look at the back of the card for a behavioral health number different from the medical one, or for a named program. The Empire Plan routes mental health and substance use to Carelon at option 3 of 1-877-7-NYSHIP while UnitedHealthcare runs medical and Anthem runs hospital; EmblemHealth routes behavioral health to Carelon through the BMP or EBHSP program named on the card. When in doubt, call the number on the back and ask who authorizes applied behavior analysis.
Yes. Carelon’s national ABA Authorization Request form, effective 1/1/2026, has an “Initial Assessment” request type, and it caps 97151 at 32 units (8 hours) for the initial with up to 32 more for a reassessment supported by clinical justification. 97152 and 0362T are also listed as requiring clinical justification.
Its national ABA Authorization Request form describes 97153 as adaptive behavior treatment by protocol administered by a technician under the direction of the physician/QHP, “receiving 1 hour of supervision for every 5 to 10 hours of direct treatment.”
There is no single national one. Carelon’s Corporate Quality Medical Management Committee approves criteria per client and regulatory requirement, and the criteria vary by state, contract and benefit — CMS criteria first for Medicare members, then custom client criteria, then ASAM, then InterQual, then Carelon’s national set. Ask which criteria set governs the specific client plan.
Availity Essentials, ProviderConnect or eServices, depending on the client plan — the handbook says you may need both Carelon portals. Link ProviderConnect and/or eServices to Availity once via single sign-on in the Availity payer space and you can reach everything from one login.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo