Provider Manual


Providers are expected to cooperate with treatment record reviews conducted by Carelon as part of health plan operations. These reviews may occur:

  • In response to a specific quality issue or concern that arises.
  • To meet account or accreditation agency requirements mandating review on a periodic basis or upon request.

Carelon will gain access to treatment records by reviewing them at the provider’s office or by asking the provider to photocopy and send the records. Prior to treating a member, the provider should obtain the member’s written consent to share their treatment information and records with Carelon. Providers must supply copies of requested records to Carelon within five (5) business days. Carelon will treat provider records confidentially as per all applicable Federal and State regulations.

Providers and vendors must, at their own expense, make all records available for audit, review or evaluation by Carelon. Access shall be provided by the provider either on-site, during regular business hours, or through the mail. During the contract and record retention periods, these records shall be available at a specific location. All mailed records shall be sent to Carelon in the form of accurate, legible, paper copies, unless otherwise indicated, within requested time frame.

Following the treatment record review, providers will receive a written report that details the findings. Included in the report will be an Action Plan with specific recommendations that will enable the provider to more fully comply with Carelon’s standards for treatment records.

Treatment records are reviewed through application of an objective instrument. The instrument is continuously under study and revision and Carelon reserves the right to alter it as needed.

For the purpose of conducting retrospective case review, clinical files pertaining to Carelon members should be maintained for six (6) years.

Carelon network providers are required to document service accessibility for the services that are provided. A network provider must provide face-to-face interventions within one hour for emergencies, within 24 hours for urgent situations, and within seven days for routine appointments and specialty referrals. Carelon collects and analyzes this data to measure performance against these contract standards. As part of a routine treatment record review, Carelon will audit for the following quality management criteria:

  • The date of the member’s initial call for an appointment,
  • The type of appointment, such as emergency, urgent or routine,
  • The date of the first appointment offered,
  • The date and the time of the actual evaluation appointment, and
  • The documentation of the reason the standard was not met, if applicable.

Diagnostic guidelines and diagnostic adherence indicators for major depression, bipolar disorder, schizophrenia, attention-deficit hyperactivity disorder, and co-occurring mental and substance related disorders are posted on our website for reference on the Provider Information Page under the Quality Management section.