Provider Manual


Because Carelon is the payor of last resort, the following guidelines apply:

  1. Providers must exhaust all avenues of other insurance coverage and payment prior to billing for covered services.
  2. When a decision regarding reimbursement has been made by another insurance carrier, a copy of the disposition of payment or explanation of benefits (EOB) must accompany the claim submission. Please include the denial reason or the denial legend with the EOB, so we can review the primary carrier’s payment or denial accurately. If this information is not included, the claim may be denied for additional information.
  3. All timely filing rules are enforced from the date of disposition from the other insurance carrier. This means providers have 90 days from the date of the explanation of benefits (EOB).
  4. Certain procedures are not subject to third party liability (TPL).
  5. Please refer to the Covered Services Grid for services which are TPL Exempt
  6. For more detailed information regarding third party liability and what it means for you as a provider, please access our Third Party Liability Guide.