Provider Manual


Upon receipt of a request for authorization for services, by phone, electronic, or fax transmittal, Carelon has ten (10) business days to enter a provider’s authorization. Providers should be able to access authorizations within 2 business days of a decision. An icon will appear on the ProviderConnect home page indicating that new authorization letters are available. Click on the link on the ProviderConnect home page to go to links to new authorization letters. Print the letters or save them to your computer. Only approval letters are electronic. Adverse determination letters and return of incomplete requests will continue to be sent to providers via US Mail. Providers may also request a fax-back copy of an authorization letter via touch tone telephone. Call 1-866-409-5958 and have available the provider NPI, fax number to receive the fax-back document, member ID number, authorization dates requested, and authorization number (if obtained previously).

If, for any reason, the provider finds it necessary to request a retro-authorization for service(s), the request must be received in writing no later than forty-five (45) calendar days from the date of service. The request for retro-authorization must be faxed (855-439-2444) to the attention of the Clinical Department or mailed to the attention of:

Clinical Department
P.O. Box 1840
Cranberry Twp., PA 16066-1840

The request for a retro-authorization only guarantees consideration of the request. The provider will receive written notification within thirty (30) calendar days from Carelon’s receipt of the request, approving or denying the service. Any requests for retro-authorization(s) received beyond forty-five (45) calendar days from the date of service will not be given consideration.

Payment for Retro-Authorizations

If the provider received written approval for the retro-request for service(s) and has not previously submitted a claim, the provider should follow the procedures as outlined in the Carelon Provider Manual for submission of claims adjustments, outlined in Section VI of Claims Payment. The claim must be received by Carelon within ninety (90) calendar days from the date on the approval letter.

Below is the link to the Retro-Authorization form that needs to be completed and sent to the Clinical Department.

Retro Authorization Form – Pennsylvania Medicaid Only