Cardiology program

Our cardiology program is part of our utilization management (UM) programs. Carelon Medical Benefits Management (Carelon) administers the cardiology program, which works to improve health care quality and manage costs for the most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe and affordable. This is accomplished through pre-service medical necessity review of outpatient cardiovascular tests and procedures.

Procedures performed in an inpatient setting or on an emergent basis are not subject to this program’s pre-authorization requirements.

Use the tabs below to learn more about our cardiology program.

Cardiology program

Request pre-authorization

CPT code list

View codes that require notification in the cardiology section of our Pre-authorization Lists.

The following services are managed under this program:

  • Ambulatory cardiac rhythm monitoring, effective July 1, 2024
  • Arterial duplex
  • Cardiac ablation, effective July 1, 2024
  • Certain cardiac devices
  • Diagnostic coronary angiography with or without right or left heart catheterization
  • Physiologic study arterial
  • Percutaneous coronary intervention, such as coronary stents and balloon angioplasty and atherectomies; services must be submitted to Carelon for post-service review within 10 days of being performed
  • Wearable cardioverter defibrillators, effective July 1, 2024, for commercial members only

Providers ordering the services listed above must first contact Carelon to request pre-authorization. View the codes that require pre-authorization on our Pre-authorization Lists.

Cardiograph services require pre-authorization as part of our radiology program:

  • Stress echocardiography (SE)
  • Resting echocardiography (TTE)
  • Transesophageal echocardiography (TEE)
Program members

Members included in the program

Determine whether your patient's plan participates in this program by using the electronic authorization tool on Availity Essentials.

An administrative services only (ASO) group may decide to purchase this benefit during their annual renewal period. The renewal period can vary by month, depending on the group. Therefore, it is important to check the electronic authorization tool on Availity Essentials to determine whether a patient's participation has changed.

Submit requests

Submitting requests for cardiology services

Ordering providers (those who refer the member for cardiology services) and servicing providers (those who provide the cardiology services) should submit requests on behalf of members.

Use Carelon's ProviderPortal or call Carelon toll-free at 1 (877) 291-0509, 8 a.m.-5 p.m. (PT) Monday through Friday to request pre-authorization. Requests through the ProviderPortal may receive immediate approval.

Request pre-authorization

View codes that require notification in the cardiology section of our Pre-authorization Lists.

Register with Carelon

Register with Carelon to request cardiology services

If you are already registered with Carelon for radiology authorizations, your registration covers this program as well. All providers who will need access to the Carelon website to obtain authorization or check authorization status must register with Carelon. For large group practices, Carelon can help with the registration process.