Manual do Provedor


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Acesso aos Serviços: The extent to which the member can obtain services at the time they are needed.

Acute: Afflicted by a disease exhibiting a rapid onset followed by a short, severe course.

Advocate: A family member, guardian or provider acting on behalf of the member with the member’s permission.


  1. The process by which a member, advocate, or provider requests a non-certification by a Carelon Peer Advisor be reconsidered.
  2. The process by which a provider requests that an adverse decision regarding network participation be reconsidered.

Autorização: Approval for a specific covered service to be delivered to a member. It represents agreement that the service is clinically necessary under the Carelon Medical Criteria.

Availity Essentials: A secure, one-stop, self-service claims portal and 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 and benefits, and claim status

Balance-Billing: The practice of charging full fees in excess of reimbursable amounts, then billing the patient for that portion of the bill not covered. This practice is not allowed by Carelon.

CAFS Coordinator: Child, Adolescent and Family Services (CAFS) Coordinator are responsible for reviewing requests for BHRS, referrals for evaluations, facilitates and participates in the interagency team meeting process, reviews BHRS packets for completeness.

CareConnect: Web enabled Care Management software accessed by providers and Carelon staff. Replaced MHS system.

Certification: The number of days, sessions or visits Carelon approves as medically necessary.

Claim: A request for reimbursement under a benefit plan for health care services.

Commonwealth: Refers to the state of Pennsylvania.

Complaint (Administrative): A problem regarding a provider, institution, or MCO that any one other than a member presents either in written or oral form which is subject to resolution by Carelon.

Complaint (Member): A problem regarding a provider or the coverage, operations or management policies of the HealthChoices program that a member or advocate (e.g. family member, guardian, or provider) presents to Carelon, either in written or oral form which is subject to resolution by the county/Carelon. Advocates, including providers acting as advocates, may present a complaint on behalf of a member, if they have received written permission from the member to do so.

Revisão Simultânea: A review conducted by Carelon during a course of treatment to determine whether or not services should continue as prescribed or should be terminated, changed or altered.

Contracted Provider: Any hospital, skilled nursing facility, extended care facility, individual, organization, or agency licensed that has a contractual arrangement with an insurer for the provision of services under an insurance contract.

Coordenação de Atendimento: The process of coordinating care among behavioral health care providers and between behavioral health care providers and physical health care providers with the goal of improving overall quality of a member’s health care.

Covered Services: Mental health and substance abuse services which are within the scope of the benefit plan.

Credenciamento: In order to be eligible for participation as a Carelon network provider, you must meet Carelon credentialing criteria for your provider type (individual, agency, facility) and discipline. Credentialing begins when all documentation and information needed to complete the process has been received by Carelon. The application specifies all the necessary paperwork needed.

Critical Incident: Critical events or outcomes involving patients seeking or receiving services under Carelon that may require further analysis. Such events include but are not limited to suicide, homicide, allegations of physical abuse/neglect, assaults, breach of confidentiality, leaving AMA, medications errors, adverse reaction to medications, property damage, and other. Critical incidents also include critical events or outcomes that occur during a patient’s transition to home or an alternative level of care.

Competência cultural: The capacity of the network to address behavioral health needs of members in a manner that is congruent with their cultural, religious, ethnic and linguistic backgrounds.

Denial: A determination made by Carelon that reimbursement for a requested service will not be made. A denial can take the form of:

  1. the request is disapproved completely; or
  2. the provision of the requested service(s) is approved, but for a lesser scope or duration than requested by the provider (an approval of a requested service which includes a requirement for a concurrent review by Carelon during the authorized period does not constitute a denial); or
  3. the provision of the requested service(s) is disapproved, but provision of an alternative service(s) is approved.

Departamento: The Pennsylvania Department of Human Services

Department of Human Services Fair Hearing: For the purposes of this document, a hearing conducted by the Department of Human Services, Bureau of Hearings and Appeals in response to a grievance to the Department by a Carelon member.

Diagnosis (Dx): A classification for mental health and substance abuse related disorders, which may be defined on as many as five axes. Carelon uses the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association as its standard. The ICD-9CM is an international version, which includes both medical and mental health diagnoses.

Disenrollment: The termination of a practitioner, group practice or facility as a Carelon participating provider. Disenrollment can be initiated by Carelon or the participating provider, either with or without cause, in accordance with the contract terms.

Planejamento de descarga: The evaluation of a member’s mental health or substance abuse service needs, or both, in order to arrange for appropriate care after discharge from one level of care to another level of care.

DHS: Department of Human Services

Dual Diagnosis: Used to describe an individual who has co-occurring psychiatric and substance use disorder diagnoses, developmental disorders, and/or medical diagnoses.

Eligibility: The determination that an individual meets the requirements to receive health care benefits as defined by the plan.

Eligibility Verification System (EVS): The Commonwealth of Pennsylvania’s automated system available to providers for on-line verification of eligibility.

Explanation of Benefits (EOB): A statement mailed to providers explaining why a claim was or was not paid.

Grievance: Grievance is a request by a Member, Member Representative, or Provider (with written consent of the Member) to reconsider a decision concerning the medical necessity and appropriateness of a covered service.

Heath Insurance Portability and Accountability Act of 1996 (HIPAA): A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable heath care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.

HealthChoices: The name of Pennsylvania’s 1915(b) waiver program to provide mandatory managed health care to Medical Assistance (MA) Members.

HealthChoices Southwest (HC-SW) Zone: The HealthChoices mandatory managed care program implemented in Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland Counties.

Inpatient Services: Medical services for behavioral health conditions provided in a setting requiring the member to stay in the facility overnight.

Length of Stay: The number of days that a member remains in a given level of care.

Level of Care: The intensity of professional care required to achieve the treatment objectives for a specific episode of care.

Medical Necessity or Medically Necessary: Clinical determinations to establish a service or benefit which will, or is reasonably expected to:

  1. prevent the onset of an illness, condition, or disability;
  2. reduce or ameliorate the physical, mental, behavioral, or developmental effects of an illness, condition, injury, or disability;
  3. assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities appropriate for individuals of the same age.

Member: Any individual who is covered by the benefit plan.

Negative Balance: The dollar amount over-paid for services rendered.

Non-certification: In those cases in which the provider has not demonstrated medical necessity for proposed or continuing services at a particular level of care, a non-certification is rendered by Carelon. The non-certification constitutes a recommendation to the payer that services not be eligible for reimbursement under the benefit plan.

Non-Participating Provider or Out-of-Network Provider: A practitioner, group practice or facility that does not have a written provider agreement with Carelon and therefore is not considered participating in the network.

Outpatient Services: Mental health and substance abuse services provided in an ambulatory care setting, such as a mental health or substance abuse clinic, hospital outpatient department, community health center, or Provider’s office. Outpatient Services include but are not limited to such services as: Individual, Family, Couple, and Group therapy; Medication Management, Diagnostic Evaluations, Case Management, and Family based Services.

Outpatient Registration Form (ORF1): A Carelon form used to review outpatient mental health and/or substance abuse treatment for the certification of medically necessary services.

Participating Provider: A practitioner, group practice or facility whose credentials, including, but not limited to, degree, licensure, certifications and specialists, have been reviewed and found acceptable by Carelon to render services to Carelon members and be reimbursed at discounted rates.

Peer Advisor: A Carelon licensed psychiatrist, licensed psychologist, or master’s level licensed professional who provides peer reviews and clinical consultations on cases.

Pre-Authorization: A determination made by Carelon to approve or deny a provider’s request to provide a service or course of treatment of a specific duration and scope to a Member prior to the provider’s initiating provision of the requested service.

ProviderConnect: Web-based application developed and maintained by Carelon IT staff that allows providers to conduct transactions via a secured site including eligibility inquiries, claims inquiries, claims submission and care registration via the Internet.

Quality Assurance/Improvement: A structured system for continually assessing and improving the overall quality of service delivered to members.

Recredencial: The review process of determining if a provider continues to meet the criteria for inclusion as a Carelon participating provider. This process occurs every two years for individual practitioners and every three years for facilities.

Retrospective Review: The process of determining necessity for care by case review after treatment has been completed.

Service Management/Manager: Carelon function/staff with responsibility to authorize and coordinate the provision of in-plan services. Care management/manager is synonymous.

Site Visits/Treatment Record Reviews: As part of provider selection and quality monitoring, site visits and treatment record reviews will be conducted on selected providers as part of the credentialing and recredentialing process. Carelon has developed site visit and treatment record review criteria based on Carelon’s standards and the requirements of NCQA.

Utilization Management: The process of evaluating the necessity, appropriateness, and efficiency of behavioral health care services against established guidelines and criteria.