Statement of Rationale and Coverage Criteria

The purpose of the Carelon Health Advanced Primary Care (APC) UM Program is to establish a structured and consistent process for prior authorization (PA), concurrent, retrospective, and post-service reviews of inpatient and outpatient services, in compliance with health plan and regulatory requirements. This process safeguards the provision of medically necessary and quality patient care through effective and timely utilization of resources.

The Carelon Health APC UM team evaluates requests for coverage determinations. Coverage determinations are based on the following hierarchy:

• Statute, CMS Coverage Manuals (e.g. Medicare Policy Benefit Manual, Medicare Managed Care Manual, Medicare Claims Processing Manual)
• CMS Guidelines, Medicare National Coverage Determinations (NCDs)
• Local Coverage Determinations (LCDs)
• State Specific Guidelines for Exclusively Aligned Enrollment (EAE) requests 
• Compendia, Micromedex, Up to Date and/or Guidance from the U.S. Food and Drug Administration (FDA)
• Member’s EOC
• Member’s Health Plan Policy

Carelon Health also utilizes externally developed clinical criteria. Those documents can be reviewed here