Provider Information

Caring for Our Communities | ACT 62 | Claims | Clinical/UM | Quality Management | Provider Enrollment | Provider Relations | Beaver | NWBHP | Formularies | Resources for Special Populations Caring for Our Communities

Caring for Our Communities

• Caring for Our Communities – How do we pick ourselves up from the ashes of trauma and tragedy? How do we get through the everyday disappointments and setbacks of life? Life will get better, and we need to nurture a vision of how to make it better. Visit these resources for Carelon members and providers alike.

ACT 62

ACT 62 Information

• Autism Coverage – Acceptable Benefit Verification Information
• Carelon ACT 62 Fax Cover Sheet
• Frequently Asked Questions Updated July 2024

Claims

Claims Dept

• Appendix AA — Prior Authorization Requirements
• Paper Claims Submission Address: (For new and corrected paper claims) Carelon Pennsylvania Claims P.O. Box 1853 Hicksville, NY 11802-1853
• CMS-1500 Instructions
• CMS Place of Service Codes
• Explanation of Payment (EOP) Codes
• Free Medicare Consumer Workbook
• Frequently Asked Questions from the Member and Provider Service Representative
• ICD-10 Frequently Asked Questions
• National Provider Identifier (NPI) Frequently Asked Questions
• PaySpan Frequently Asked Questions
• PaySpan Payer User Guide
• PaySpan Provider User Guide
• CMS ICD-10 Code Lookup
• Coding Conversion Tool
• UB-04-CMS-1450 Instructions
• Carelon Billing Guide
  • Customer Service Audio Recordings (Helpful Tips)
    • Adjustment Request
    • Authorization
    • Secondary Claims Adjustment
• Carelon Provider Guide to Using Direct Claim Submission
• Carelon Provider Guide to Changing or Reprocessing Professional Claims
• 5010 File Submissions
  • 5010 Companion Guide
  • 5010 File Submission Testing Instructions
• Paper Claims Submission Requirements
  • CMS-1500 Required Fields
  • UB-04 Required Fields

Clinical / Utilization Management

Clinical / Utilization Management

• Clinical Practice Guidelines
• Self-Management Tools
• Provider Toolkit
• Auto Auths
  • Auto Auth FAQs for Mental Health Services
  • Auto Auth FAQs for Substance Use Disorder
• Best Practice Guidelines
  • School Based Outpatient Mental Health New
  • Adult Non-Acute Partial Hospitalization Program
  • Community Residential Rehabilitation (CRR) Host Home
  • Suboxone
  • RTF
• Case Management Best Practice
• Recovery Oriented Methadone (ROM) Phases of Treatment

Quality Management

Quality Management

• 2023 Health Equity Program
• QM/UM Annual Program Evaluation Executive Summary

Provider Enrollment

Provider Enrollment

• Individual Preferred Provider Criteria for Sexual Offender Treatment
• Individual Preferred Provider Criteria for Treatment of Trauma
  • TF-CBT Brief Practice Checklist
• Provider Advisory Council

Provider Relations

Provider Relations

2024 Annual Provider Education

• Facility Education Webinar 

2023 Annual Provider Education

• Practitioner Education Webinar

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• • About Carelon
  • Deficit Reduction Act
  • HealthChoices BH Program-Program Standards and Requirements
    • HealthChoices BH Program-Appendices
  • Mental Health Advance Directives: Instructions for Providers
  • Minimum Documentation Standards
  • PROMISe Enrollment/Revalidation/Reactivation Online
  • Provider Advisory Council Membership Directory
  • Provider Covered Services Grid – HIPAA Compliant

PA DHS/OMHSAS Information

• Pennsylvania Suicide Prevention Resource Guide
• Pennsylvania Code and Bulletin
• Pennsylvania Department of Human Services Bulletin Search
• Department of Drug and Alcohol Programs
• OMHSAS Bulletin 22-08-Peer Support Services – Revised 12/28/22
• OMHSAS Bulletin 19-02 PROMISe Service Location Enrollment
• MA Bulletin: Statewide Preferred Drug List Implementation – Effective January 1, 2020
• OMHSAS Policy Clarification #03-16-01: Encounter Coding
• OMHSAS Policy Clarification #01-14-01: Payment for Diagnostic Laboratory Services in Outpatient D&A Clinics
• DHS [55 PA CODE, CHAPTER 5260] Family Based Mental Health Services for Children and Adolescents
• MA Bulletin (99-10-14) Issued/Effective 12-01-10 “Missed Appointments”

Beaver

County Specific Provider Information

Beaver County

• System of Care

Formularies

Formularies

• Pennsylvania Medical Assistance Statewide Preferred Drug List Information

Resources for Special Populations

Resources for Special Populations

• Resource Guide for Supporting Deaf, DeafBlind, and Hard of Hearing Individuals