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Musculoskeletal Program

Carelon℠ Medical Benefits Management (Carelon) offers a Musculoskeletal Program to certain self-insured employer group health plans administered by Horizon. The program helps health care professionals manage the complexities associated with musculoskeletal and interventional pain management services.

Carelon conducts Prior Authorization/Medical Necessity Determination (PA/MND) reviews of certain musculoskeletal pain management and outpatient arthroscopic joint surgeries to improve health care quality and manage health care costs, helping to promote care that is appropriate, safe and affordable.

Doctors and other health care professionals who order outpatient musculoskeletal services for their patients can contact Carelon through their Provider Portal or by phone prior to providing service. This allows the Carelon prospective review to occur and for the doctors and other health care professionals to receive the qualitative feedback afforded by Carelon’s quality improvement programs.

If the planned services do not meet the Carelon guidelines for medical necessity, Carelon may suggest that the doctor or other health care professional consider offering an alternative service or withdraw the requested service entirely.

Pre-service review requirements

Providers must contact Carelon for PA/MND review before performing the following non-emergency modalities:

Joint surgery (Outpatient Place of Service Only)

  • Hip arthroscopy
  • Knee arthroscopy
  • Meniscal allograft transplantation
  • Shoulder arthroscopy
  • Total hip replacement
  • Total knee replacement
  • Total shoulder replacement
  • Treatment of osteochondral defects

Interventional pain management

  • Epidural steroid injections
  • Paravertebral facet joint injection/Nerve block/Neurolysis
  • Regional sympathetic nerve block
  • Sacroiliac steroid injections
  • Spinal cord stimulators

Surgeries and pain treatments performed as part of an inpatient admission are excluded.

How to place a review request:

To submit a request, register or sign in to the Carelon Provider Portal. Providers may also call Carelon at 1-866-766-0250, then press 1, Monday through Friday, from 9 a.m. to 6 p.m., Eastern Time (ET). This number is also displayed on the back of the member's ID card.

For more information:

Helpful information, order entry worksheets and FAQs are available online. Sign in to the Carelon Provider Portal and select Musculoskeletal.

For general information about Carelon, call 1-847-564-8500, weekdays, from 9 a.m. to 6 p.m., ET.

Carelon℠ Medical Benefits Management supports Horizon 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.