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Diagnostic Imaging Program

Carelon℠ Medical Benefits Management (Carelon) offers a Diagnostic Imaging Program to certain self-insured employer group health plans administered by Horizon. This diagnostic imaging program is designed to help members make informed heath care decisions.

Horizon is committed to administering a comprehensive diagnostic imaging management program designed to:

  • Improve the clinical appropriateness of imaging services through the application of evidence-based guidelines in an efficient and effective review process.
  • Maximize the value from our network through a wide range of solutions, including assessment tools, cost and quality transparency and reporting.
  • Engage members and increase their understanding of the range of choices they have in selecting among imaging providers making informed decisions.

The following procedures are included in the program:

  • Computed tomography (CT)
  • Computed tomography angiography (CTA)
  • Magnetic resonance imaging (MRI)
  • Magnetic resonance angiography (MRA)
  • Positron emission tomography (PET and PET-CT)
  • Nuclear cardiology:
    • Blood pool imaging
    • First pass ventriculography
    • Infarct imaging
    • MUGA
    • Myocardial perfusion imaging (MPI)

Providers should contact Carelon (see below) to obtain an order number before scheduling or performing any elective outpatient imaging service.

Services performed in conjunction with Emergency Room services, inpatient hospitalization or urgent-care facilities are excluded. Both ordering physicians (those referring the member for imaging) and servicing providers (those free-standing or hospitals that perform imaging) may submit requests. We recommend that servicing providers confirm an order number has been issued before rendering services.

How to Request a Review

  • Submit a request using the Carelon Provider Portal.
  • Call Carelon at 1-866-766-0250, option 1, weekdays, from 9 a.m. to 6 p.m., Eastern Time (ET).

Carelon Clinical Appropriateness Guidelines for Radiology

Horizon's diagnostic imaging program follows the Carelon Clinical Appropriateness Guidelines for Radiology..

The Carelon clinical guidelines are developed and revised through a rigorous review process that uses a comprehensive assessment of existing guidelines, evidence based standards and literature, and extensive feedback from the Carelon External Physician Specialty Advisory Panel, which includes board-certified physicians from both community and academic practice.

For More Information

Carelon℠ Medical Benefits Management supports Horizon Blue Cross Blue Shield of New Jersey in the administration of specialty benefits management. Carelon Medical Benefits Management is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.