Manual do Provedor


The Carelon approach to service authorization for the HealthChoices program has been shaped by the purchasing specifications outlined in DHS’s Request for Proposal and the DHS HealthChoices Program Standards and Requirements document effective January 1, 2004. It has also been guided by our shared vision with the counties that the HealthChoices Program will meet the goals of improving the accessibility, continuity, and quality of services for Pennsylvania’s Medical Assistance population, while controlling the program’s rate of cost increases. The Carelon Engagement Center, located in Cranberry Township, PA, serves as the hub of our program’s clinical and operational activities. Our 24-hour phone line is staffed by Service Managers to receive emergency, urgent and routine calls from members, providers, and family members. In addition to our continual emergency response capabilities, our Service Managers/CAFS Coordinators provide referrals, pre-authorizations, and concurrent review services. The Carelon Clinical Service Management program has been developed with the following key goals in mind:
  • Facilitar a coordenação, continuidade e integração eficientes na prestação de serviços de saúde comportamental;
  • Fornecer aos indivíduos acesso a todos os serviços de saúde mental e abuso de substâncias clinicamente necessários e apropriados, de acordo com os padrões de atendimento do DHS;
  • Coordenar a prestação de serviços de saúde comportamental com a componente de serviços de saúde física do programa HealthChoices;
  • Coordenar os serviços de saúde comportamental com uma gama mais ampla de programas de serviços humanos com financiamento público, bem como os sistemas informais de apoio da comunidade aos membros;
  • Gerencie as despesas do programa de maneira econômica por meio do gerenciamento apropriado da utilização do serviço, custos do serviço e despesas administrativas.
Our Member and Provider Service lines are open from 8:00 a.m. to 5:00 p.m., Monday through Friday, to answer questions about the program, covered services, and claims inquiries. Member and Provider Service Representatives provide general information, answer questions, and solve problems for both members and network providers. If necessary, they will refer providers to their designated Provider Field Coordinator. Carelon monitors its participating provider network on a continual basis in order to ensure compliance with the Commonwealth’s access standards. Our Network Operations department maintains all demographic information regarding the provider, including the provider’s network status and type of services they offer. Reimbursement schedules and contract amendments are also handled through Network Operations. Claims are received, processed and paid directly from the Pennsylvania Engagement Center. By understanding the complexities of our contracts, we are able to more quickly and efficiently serve our network providers. The Member and Provider Service staff is able to view the status of claims in our system and provide feedback on any inquiries. They also handle all requests for claims adjustments. Carelon’s Quality Management and Medical Affairs staffs are also based at the Engagement Center and operate under the tenets of the Quality Management Program. The Management Information Systems (MIS) staff is housed here as well and is primarily responsible for all internal and external reporting deliverables. Finally, Carelon’s management, senior management, and financial staff are all located in the Pennsylvania Engagement Center.