GOING ONLINE WITH CARELON
Carelon’s Online Provider Services are designed to give providers easy access to eligibility inquiry, claims status inquiry, electronic claims submission, and provider summary vouchers. These services are provided at no cost to our network providers. Providers can electronically submit claims to our system via a direct, secured modem connection or submit outpatient claims through ProviderConnect, our VeriSign™ secure Internet website. To access ProviderConnect, visit http://pa.carelon.com/providers. To obtain a User ID, click on register, complete the required form, and click on “submit.”
Users with questions regarding Carelon’s Online Provider Services may review the information on this website. Choose “For Providers”, then “ProviderConnect”, then “Log In”. Providers may also contact our e-Support Services Help Line at 888-247-9311, Monday through Friday from 8:00 am until 8:00 pm Eastern Time or via e-mail at
- Availity Essentials
Availity Essentials is a secure, one-stop, self-service claims portal.
Beginning on March 1, 2022, Availity Essentials becomes the preferred multi-payer portal of choice for submitting the following transactions to Carelon:
- Claim Submissions (Direct Data Entry Professional and Facility Claims) applications or EDI using the Availity EDI Gateway
- Eligibility & Benefits
- Claim Status
- Online Advantages
Claims filed electronically reduce the handling costs (forms, purchase, labor, postage, etc.) associated with paper claim filing. Providers can submit claims electronically to our system via a direct, secure website.
Claim files that pass format verification are transferred to our claims processing systems the following business day, eliminating the need for manual handling & data entry of claims. This process reduces the amount of time it takes to be paid for your claims.
Authorized providers can check eligibility and submit and track claims using Online Services. Questions regarding claims payment or eligibility that are not answered through Online Services should be addressed with the Carelon Engagement Center.
- Becoming an Online User
Providers must obtain a User ID before using Online Services.
Upon validation of your information, we will provide a User ID and password for Carelon Online Services. This usually takes one to three business days.
- Invoice Types: Electronic Claims Submission
Carelon currently accepts the two primary invoice types for electronic claims submission: the HIPAA compliant 837 Professional and Institutional. Only invoices billed electronically in the HIPAA Standard Transaction and Code Sets format will be accepted.
If you are using Carelon’s EDI Claims Link for Windows software, the file will automatically be created in our defined layout for each of these invoices.
If you will be using your own software to create claim files, refer to the HIPAA 837 (Professional or Institutional) Implementation Guide
The Carelon’s 837 Companion Guide, which should be used in conjunction with the Implementation Guide.
- File Submission Requirements
Before you can begin to send production claim files electronically, you will be required to submit test data. This test will help ensure that the files are in the correct file formats.
Use of EDI Claims Link for Windows® (Carelon’s proprietary software) requires less testing. This software meets Carelon electronic claim file format requirements. The only testing that may be necessary is to ensure data accuracy and the transfer of claims data through the process. We strongly suggest that you limit your first few files to just a few claims in the event that you’ve entered inaccurate data that does not pass the verification process.
If you will be creating HIPAA compliant claim files using any program other than Carelon EDI Claims Link for Windows®, you must submit a test file prior to sending production claims data. This test submission will be run through our file format verification program. This program verifies your file submission against the format specifications. You must obtain your Test User ID and Password before attempting to send a test file. Your test file must contain your Test User ID in order to be accepted for testing. Once you have successfully completed testing, e-Support Services will activate your Production User ID.
You will receive feedback for each file you submit. You will be notified by a message to your mailbox, on our bulletin board system or to your Internet e-mail account whether your file passed the format verification process. If you submit your file using our Web interface, the tracking number that appears on the screen provides a link to your file feedback. If your file failed format verification, the feedback will provide explanations for the failure. Any error message you do not understand can be explained by e-Support Services. Please note that the file format verification process only checks the format of the file. This process does not verify accuracy of claims data and does not guarantee that the claim will be paid. Normal claims payment rules apply.
Production files may be submitted to Carelon seven days per week, 24 hours per day unless system downtime is reported on our Web site. Carelon periodically takes the system down for maintenance and notifies users in advance whenever possible.
- File Submission Checklist
In order to successfully submit a file, you must know:
- your User ID and password
- the total number of claims
- the total dollars billed in each file
The information you enter at these prompts during the upload process must match the information on the actual file in order for the upload to be successful.
Whether you submit your file using our web interface or the BBS, our system will validate and either accept or reject your entire file submission. For this reason, we strongly suggest that your first file contains few claims. If one claim on the file contains data that prevents it from passing our format verification process, the entire file will be rejected.
- Methods for File Submission
There are two ways to submit files to Carelon:
Files may be submitted to our Internet Web site if you have a browser with an appropriate security level that supports 128-bit encryption (such as Internet Explorer 5.01 or greater). Simply log in using the User ID and password assigned.
Files may be submitted via direct, secured, modem connections to our Bulletin Board System at 888-685-2595
- Carelon’s Electronic Claim Submission Policies
- System Upload Processing
Instructions for uploading electronic claims files to Carelon may be found in the EDI Claims Link for Windows® Version 3.0 User’s Manual. E-Support Services is also available to provide information on the upload process and/or answer questions about our software.
- Direct Claims Submission
Users have the ability to submit single claims online without the need to create a batch for just one claim. This benefits low volume submitters. Once provider and member information is entered and validated, the user will be prompted to provide the remainder of the information required to complete the claim. The results page will contain real-time adjudication information.
- Claim Status Inquiry
Users have the ability to look up the status of their claims through our Online Services. The user must know the member number, member date of birth and claim date of service. A date range can also be used, if the user prefers to look up several months’ worth of claims for a given member. This alleviates calls to customer service to check claim status.
For security and confidentiality reasons, Carelon validates the “pay-to” provider ID associated with the user ID. This information is captured when you request a user ID for Online Services. If you receive a new provider ID from Carelon, please contact e-Support Services to ensure your provider ID is updated for Online Services. Users with more than one “pay-to” provider ID will be required to provide all provider IDs.
- Eligibility Inquiry
Users have the ability to check the eligibility status of a member who comes to them for care. The eligibility shown is a current snapshot and will not reflect the member’s past or future eligibility status. You must still follow the normal business procedures for authorizing and/or registering care. Active eligibility on our system does not guarantee authorization of services.
- Contact Us
Phone: 1-800-282-4548, Monday – Friday, 8 a.m. to 8 p.m. EST