Provider Manual


Carelon will ensure that referrals to providers and between providers are coordinated with the goals of maintaining continuity of care and the clear communication of salient clinical information.

Referrals Made by Carelon to Providers

The goal of Carelon in making referrals to providers is to ensure that members receive access to service in a timely manner, according to their clinical needs.

When calls from members come into the Carelon Engagement Center, a Service Manager assesses the member’s needs in order to triage the call into an emergency, urgent, or routine level of acuity.

Members whose needs are assessed to be emergent in nature are immediately referred to the closest facility or agency best able to meet their clinical needs.

Members whose need for treatment is urgent or routine are referred for further evaluation with a local provider who can meet the HealthChoices access requirements. (These standards require that emergencies have face-to-face contact with a provider within 60 minutes, urgent referrals within 24 hours, and routine referrals within seven days.) Following the requirements of the Commonwealth, the member must always be offered the choice of at least two providers, as long as the providers can meet the member’s language and cultural needs. The Carelon provider database allows our Service Managers/CAFS Coordinators to ascertain the providers within the member access requirements.

Each member has the right to request a second opinion from a provider within the network at no cost to the member. If necessary, Carelon may arrange for a second opinion with a provider outside of the network.

Referrals Made Between Providers

In the event that a member requires transfer from one provider to another or from one level of care to another, the referring provider should adhere to the following procedures (except in the case of emergencies):

  1. Transfer/Referral to all Levels of Care Except Outpatient
    Referring providers should contact the toll-free provider number and proceed with the preauthorization process as described in Section III of this manual.
  2. Transfer/Referral to an Outpatient Level of Care
    Follow the outpatient care procedures as described in Section III of this manual.

Referrals Made by Carelon to Out-of-Network Providers

Carelon does not encourage making referrals to out-of-network providers. However, the following circumstances exist where this need may arise:

  • A unique or specialized service is requested that is only provided by an out-of-network provider (e.g., sexual abuse, PTSD)
  • A service is requested that is not available within the urban (30 minutes) or rural (60 minutes) access standards and for which there is an approved exception (waiver) in place.
  • A member is out of zone and requires emergency care or needs access to immediate, short-term treatment
  • A provider is currently going through the process of becoming an in-network provider and a member requests to be seen by this provider

All out-of-network referrals must be approved by a Clinical Manager and/or the Clinical Director.