Provider Manual


  1. Introduction

    Carelon’s Online Provider Services are designed to give providers easy access to eligibility inquiry, claims status inquiry, electronic claims submission, and provider summary vouchers. These services are provided at no cost to our network providers. Providers can electronically submit claims to our system via a direct, secured modem connection or submit outpatient claims through ProviderConnect, our VeriSign™ secure Internet website. To access ProviderConnect, visit To obtain a User ID, click on register, complete the required form, and click on “submit.”

    Users with questions regarding Carelon’s Online Provider Services may review the information on this website. Choose “For Providers”, then “ProviderConnect”, then “Log In”. Providers may also contact our e-Support Services Help Line at 888-247-9311, Monday through Friday from 8:00 am until 8:00 pm Eastern Time or via e-mail at

  2. Availity Essentials

    Availity Essentials is a secure, one-stop, self-service claims portal.

    Beginning on March 1, 2022, Availity Essentials becomes the preferred multi-payer portal of choice for submitting the following transactions to Carelon:

    • Claim Submissions (Direct Data Entry Professional and Facility Claims) applications or EDI using the Availity EDI Gateway
    • Eligibility & Benefits
    • Claim Status
  3. Online Advantages

    Claims filed electronically reduce the handling costs (forms, purchase, labor, postage, etc.) associated with paper claim filing. Providers can submit claims electronically to our system via a direct, secure website.  

    Claim files that pass format verification are transferred to our claims processing systems the following business day, eliminating the need for manual handling & data entry of claims. This process reduces the amount of time it takes to be paid for your claims.

    Authorized providers can check eligibility and submit and track claims using Online Services. Questions regarding claims payment or eligibility that are not answered through Online Services should be addressed with the Carelon Engagement Center.

  4. Becoming an Online User

    Providers must obtain a User ID before using Online Services.

    1. Online Provider Services Account Request Form

      This form authorizes Carelon to receive and process claims electronically and certifies that claims will comply with all laws, rules and regulations governing your contract with Carelon. Providers who wish to have inquiry-only access to our system for the purpose of conducting eligibility inquiries and claim status inquiries must also submit this form. All Online Services users must complete this form.

    2. Online Provider Service Intermediary Authorization Form

      This form authorizes an external entity such as a billing agent or clearinghouse to submit claims on the provider’s behalf. This form must be completed only if the provider utilizes the services of a billing agency, clearinghouse or other third party.

    Upon validation of your information, we will provide a User ID and password for Carelon Online Services. This usually takes one to three business days.

  5. Invoice Types: Electronic Claims Submission

    Carelon currently accepts the two primary invoice types for electronic claims submission: the HIPAA compliant 837 Professional and Institutional. Only invoices billed electronically in the HIPAA Standard Transaction and Code Sets format will be accepted.

    If you are using Carelon’s EDI Claims Link for Windows software, the file will automatically be created in our defined layout for each of these invoices.

    If you will be using your own software to create claim files, refer to the HIPAA 837 (Professional or Institutional) Implementation Guide

    The Carelon’s 837 Companion Guide, which should be used in conjunction with the Implementation Guide.

  6. File Submission Requirements

    Before you can begin to send production claim files electronically, you will be required to submit test data. This test will help ensure that the files are in the correct file formats.

    Use of EDI Claims Link for Windows® (Carelon’s proprietary software) requires less testing. This software meets Carelon electronic claim file format requirements. The only testing that may be necessary is to ensure data accuracy and the transfer of claims data through the process. We strongly suggest that you limit your first few files to just a few claims in the event that you’ve entered inaccurate data that does not pass the verification process.

    If you will be creating HIPAA compliant claim files using any program other than Carelon EDI Claims Link for Windows®, you must submit a test file prior to sending production claims data. This test submission will be run through our file format verification program. This program verifies your file submission against the format specifications. You must obtain your Test User ID and Password before attempting to send a test file. Your test file must contain your Test User ID in order to be accepted for testing. Once you have successfully completed testing, e-Support Services will activate your Production User ID.

    You will receive feedback for each file you submit. You will be notified by a message to your mailbox, on our bulletin board system or to your Internet e-mail account whether your file passed the format verification process. If you submit your file using our Web interface, the tracking number that appears on the screen provides a link to your file feedback. If your file failed format verification, the feedback will provide explanations for the failure. Any error message you do not understand can be explained by e-Support Services. Please note that the file format verification process only checks the format of the file. This process does not verify accuracy of claims data and does not guarantee that the claim will be paid. Normal claims payment rules apply.

    Production files may be submitted to Carelon seven days per week, 24 hours per day unless system downtime is reported on our Web site. Carelon periodically takes the system down for maintenance and notifies users in advance whenever possible.

  7. File Submission Checklist

    In order to successfully submit a file, you must know:

    • your User ID and password
    • the total number of claims
    • the total dollars billed in each file

    The information you enter at these prompts during the upload process must match the information on the actual file in order for the upload to be successful.

    Whether you submit your file using our web interface or the BBS, our system will validate and either accept or reject your entire file submission. For this reason, we strongly suggest that your first file contains few claims. If one claim on the file contains data that prevents it from passing our format verification process, the entire file will be rejected.

  8. Methods for File Submission

    There are two ways to submit files to Carelon:

    Files may be submitted to our Internet Web site if you have a browser with an appropriate security level that supports 128-bit encryption (such as Internet Explorer 5.01 or greater). Simply log in using the User ID and password assigned.

    Files may be submitted via direct, secured, modem connections to our Bulletin Board System at 888-685-2595

  9. Carelon’s Electronic Claim Submission Policies
    1. Carelon will only accept files for processing that meet the file format specifications as outlined in the HIPAA 837 Implementation Guide. The Carelon 837 Companion Guide supplements, but does not replace or contradict any requirements in, the Implementation Guide.
    2. All requirements as outlined in this manual are fulfilled.
    3. An authorized representative of the provider, their agents or assignees may request documentation to ensure that all requirements are met.
    4. Any applicable local, state, and/or federal regulatory agents may request actual information used to bill claims electronically. All information thus obtained will be held in confidence according to applicable local, state, and/or federal laws and regulations.
    5. The provider for whom claims are submitted is ultimately responsible for the accuracy and validity of all such claims submitted for payment consideration. Any provider utilizing the services of a third-party entity to report claim information must be in compliance with all local, state, and federal policies and regulations. Both the provider and the third-party entity are required to maintain a record of all services submitted to Carelon for payment consideration.
    6. Any client/patient information collected by and held within the billing/accounting system of a provider or third-party entity must conform to all applicable local, state and federal confidentiality laws, policies, and regulations.
    7. Carelon retains the right to return, reject, or disallow any claim, group of claims or claims files received via the Carelon System pending that claim, group of claims, or claims files correction is in compliance with the file format requirements as stated in the documents cited in Item 1 above.
    8. A provider may utilize only one third-party entity per type of invoice for any period of time. Billing electronically through multiple billing agencies, clearinghouses or other third-party entities for the same invoice type is not permitted. E-Support Services must be notified if a provider changes billing entities.
    9. Billing agents, clearinghouses or other third-party entities are required to ensure that an “Intermediary Authorization Form” is on file for each provider contained in any files submitted by said agent.
  10. System Upload Processing

    Instructions for uploading electronic claims files to Carelon may be found in the EDI Claims Link for Windows® Version 3.0 User’s Manual. E-Support Services is also available to provide information on the upload process and/or answer questions about our software.

  11. Direct Claims Submission

    Users have the ability to submit single claims online without the need to create a batch for just one claim. This benefits low volume submitters. Once provider and member information is entered and validated, the user will be prompted to provide the remainder of the information required to complete the claim. The results page will contain real-time adjudication information.

  12. Claim Status Inquiry

    Users have the ability to look up the status of their claims through our Online Services. The user must know the member number, member date of birth and claim date of service. A date range can also be used, if the user prefers to look up several months’ worth of claims for a given member. This alleviates calls to customer service to check claim status.

    For security and confidentiality reasons, Carelon validates the “pay-to” provider ID associated with the user ID. This information is captured when you request a user ID for Online Services. If you receive a new provider ID from Carelon, please contact e-Support Services to ensure your provider ID is updated for Online Services. Users with more than one “pay-to” provider ID will be required to provide all provider IDs.

  13. Eligibility Inquiry

    Users have the ability to check the eligibility status of a member who comes to them for care. The eligibility shown is a current snapshot and will not reflect the member’s past or future eligibility status. You must still follow the normal business procedures for authorizing and/or registering care. Active eligibility on our system does not guarantee authorization of services.

  14. Contact Us

    Phone: 1-800-282-4548, Monday – Friday, 8 a.m. to 8 p.m. EST

    EDI Helpdesk:
    Phone: 888-247-9311, Monday – Friday, 8AM – 6PM EST
    Fax: 866-698-6032

    Online Provider Services Account Request Form