Carelon Behavioral Health Prior Authorization Guide 2026
Carelon Behavioral Health prior authorization for Anthem and other plans: Availity routing, InterQual and ASAM criteria, peer review, and appeal clocks.
On this page: Direct answer
Direct answer
Carelon behavioral health prior authorization: what operators need to know
Carelon Behavioral Health prior authorization for Anthem and other plans: Availity routing, InterQual and ASAM criteria, peer review, and appeal clocks. Route Anthem requests through Availity under the Anthem payer ID; other Carelon-managed plans use payer ID BHOVO to reach ProviderConnect or eServices.
Carelon Behavioral Health, which Elevance Health describes as formerly Beacon Health and part of its Carelon services brand, manages mental health and substance use services for benefit plans that contract with it, and its provider pages give Anthem plans their own authorization route. Carelon's handbook states the general pattern: subject to benefit plan requirements, inpatient care and other higher levels of care generally require prior authorization or notification of the admission, while outpatient care is reviewed when clinical factors call for it.
The hard parts are routing and criteria. Anthem requests go through Availity under the applicable Anthem payer ID; other Carelon-managed plans use Availity under Carelon's payer ID to reach ProviderConnect or eServices. Mental health reviews usually run on InterQual, substance use reviews on ASAM, Medicare on CMS coverage documents, and some plans on custom or MCG criteria. Last verified: September 2026.
Marsa Health is not affiliated with, endorsed by, or a partner of Carelon, Elevance Health, or Anthem; the names identify the payer only. Requirements vary by plan, state, and line of business, so confirm each one on the member's plan.
Key takeaways
The short version
- Route Anthem requests through Availity under the Anthem payer ID; other Carelon-managed plans use payer ID BHOVO to reach ProviderConnect or eServices.
- Carelon applies CMS coverage documents for Medicare, then custom criteria, then ASAM for substance use and InterQual for mental health, with MCG on some plans.
- In the handbook we reviewed, a denial issued without a peer-to-peer can be reconsidered within three business days of the notice.
- Handbook defaults allow 180 days for a Level I appeal and 90 days for Level II, but plans, states, and CMS programs override them.
- The handbook's 14-day CMS decision window predates CMS-0057-F; Medicare Advantage and Medicaid standard decisions are now due in 7 calendar days.
Take the template with you
Free to copy · no email required
Capture the facts that decide which Carelon path and clock apply. No patient identifiers; reference the case by your internal ID only.
1. Route the request to the right Carelon door
Anthem Blue Cross and Blue Shield's Connecticut provider news (July 1, 2025) told commercial and Medicare Advantage providers to submit behavioral health authorizations through Availity Essentials beginning August 1, 2025, under Authorizations and Referrals, on the Patient Registration tab. Check your state's Anthem provider news for its equivalent notice; we cite Connecticut because it is the notice we could verify.
| Member's plan | Where Carelon says to work | Confirm |
|---|---|---|
| Anthem commercial or Medicare Advantage | Availity Essentials under the applicable Anthem payer ID, for authorizations, claim status, and eligibility | Your Availity administrator has assigned you the Authorization role |
| Other health plans Carelon manages | Availity under Carelon payer ID BHOVO, which opens ProviderConnect or eServices | Which of the two portals your contract uses |
| Any plan, when a portal cannot take the request | The number on the member's ID card; Carelon's National Provider Services Line, 800-397-1630, weekdays 8 a.m. to 8 p.m. ET, for general questions | Plan-specific phone paths printed on the card |
2. Which levels of care need review
Carelon does not publish one national code list; the member's benefit plan sets it. The handbook's language is that inpatient covered services and other higher levels of care generally require prior authorization or notification of the admission, and that details of each benefit plan's requirements are available in Carelon's provider portals.
| Level or service | What Carelon's public materials say | Confirm on the member's plan |
|---|---|---|
| Inpatient psychiatric and inpatient detox | Generally require prior authorization or notification; contact Carelon within 48 hours of an emergency admission unless your agreement says otherwise | The plan's notification route and clock |
| Residential, PHP, and IOP | Care managers may authorize the levels the member's plan specifies, such as residential, partial hospitalization, or intensive outpatient | Whether the plan requires prior authorization, notification only, or neither |
| Routine outpatient therapy | Some plans allow initial encounters without authorization, counted per provider and refreshed after a six-month break in treatment | How many initial encounters that plan allows |
| Psychological testing, TMS, ABA | Not itemized in the national materials we reviewed | The plan's own precertification list |
| Retrospective requests | Available only when the benefit plan allows; otherwise they may be administratively denied | Whether the plan permits retro review and the documented reason for delay |
3. Criteria: InterQual for mental health, ASAM for substance use
Carelon's current Medical Necessity Criteria page describes a decision order rather than one tool. Work through it the same way when you prepare a request, so your documentation speaks the language of the set the reviewer will open.
- MCG Behavioral Health Care criteria are used for some plans
- In New York, only InterQual continued-stay criteria are used for mental health reviews, wherever the member is in the treatment episode
- Criteria are linked online where possible and available on request; licensed sets sit behind Carelon's criteria portal login
- The criteria page names The ASAM Criteria without stating an edition, so ask which edition the reviewer applied
- 01
Medicare member
Carelon first looks for a relevant CMS national or local coverage determination.
- 02
Custom criteria
If no CMS document applies, Carelon checks for custom medical necessity criteria for that plan or state.
- 03
Substance use service
The ASAM Criteria apply, except substance use laboratory testing, which uses InterQual.
- 04
Mental health service
Change Healthcare's InterQual Behavioral Health Criteria apply.
- 05
Nothing else fits
Carelon Behavioral Health's National Medical Necessity Criteria are the fallback.
4. Concurrent review: finish before the last covered day
- Carelon asks providers to complete the continued-stay review 24 hours before the current authorization ends
- Continued-stay reviews focus on current severity, the intensity of the treatment plan, progress, and discharge planning
- Care managers cannot deny a request; cases that do not appear to meet criteria go to a peer reviewer
- Carelon prefers portal submission, available around the clock, and care managers are available 24/7 to conduct reviews when the portal cannot
| Request type | Handbook default | 2026 note |
|---|---|---|
| Prospective urgent | 72 hours | Matches the CMS-0057-F expedited clock for MA and Medicaid |
| Prospective non-urgent | 15 calendar days (14 for CMS contracts) | MA and Medicaid standard decisions are due in 7 calendar days from January 1, 2026 |
| Concurrent urgent, requested more than 24 hours before expiration | 24 hours | Mirrors the ERISA rule for urgent extension requests |
| Retrospective | 30 calendar days | Only when the plan allows retro review |
5. Peer review, reconsideration, and appeal
In the handbook, only a psychiatrist (and, for some levels of care, a doctoral-level clinical psychologist) can clinically deny a request. The peer reviewer may call the attending provider for a peer-to-peer conversation, and after an adverse decision the provider can call the plan's toll-free number to speak with the reviewer who made it. Denial notices must give the specific reasons and say that the criteria used are available on request.
| Path | When it applies | Handbook default |
|---|---|---|
| Reconsideration | Medical-necessity denial issued without a peer-to-peer, or administrative denial after a missed peer-to-peer request | Request within three business days of receiving the notice |
| Level I appeal | Any adverse determination | Up to 180 calendar days from the notice; verbal, written, or fax |
| Level II appeal | Where the member's plan offers a second level | Up to 90 calendar days from the Level I decision |
| Expedited appeal | Member in urgent care when the appeal is filed | Decision within 72 hours |
| Standard appeal | Non-urgent care | Decision within 15 calendar days |
| Claim appeal | Payment determination disputes | Complete request within 60 calendar days; decision within 30 calendar days |
6. Federal rules that change the Carelon defaults
- Medicare Advantage and Medicaid managed care: CMS-0057-F requires standard decisions within 7 calendar days, expedited decisions within 72 hours, and a specific reason for each denial from January 1, 2026
- Individual plans on a Federally Facilitated Exchange: the specific-denial-reason requirement applies; the new decision clocks do not
- Employer plans under ERISA: urgent decisions within 72 hours, pre-service within 15 days, and at least 180 days to appeal
- MHPAEA: MH/SUD medical-necessity criteria must be available on request; the Labor Department's May 15, 2025 non-enforcement statement covers only parts of the 2024 rule that are new relative to the 2013 rule
- The handbook also says a provider may not bill the member for non-certified services until all available appeals are exhausted and the member agrees in writing
7. A three-day response plan for a Carelon denial
- 01
Day 0: read the notice
Record the specific reason, the criteria set cited (InterQual, ASAM, custom, MCG, or CMS), the notice date, and whether a peer-to-peer took place.
- 02
Day 0: choose the path
If no peer-to-peer happened before the denial, the handbook's reconsideration window is three business days. Otherwise move to a Level I appeal, or an expedited appeal if the member is still in urgent care.
- 03
Day 1: get the criterion
Request the exact criterion applied if it is not attached, and note which ASAM edition or InterQual subset the reviewer used.
- 04
Day 1 to 2: answer point by point
Quote the denial reason, then map dated chart evidence to each unmet element of the cited criterion.
- 05
Day 2 to 3: human sign-off
A named clinician reviews and submits. Log the time, channel, and reference number, and calendar the decision due date.
Common questions
Answers before you build.
How do I submit an Anthem behavioral health authorization to Carelon?+
Carelon's provider portal page tells providers to submit authorizations for Anthem plans in Availity under the applicable Anthem payer ID. Anthem's Connecticut notice moved commercial and Medicare Advantage behavioral health authorizations to Availity Essentials from August 1, 2025. Confirm the route on the member's ID card.
What criteria does Carelon use for mental health IOP or residential care?+
Carelon says it uses InterQual Behavioral Health Criteria for mental health levels of care unless a CMS coverage document or custom criteria apply, and MCG criteria for some plans. Substance use services use The ASAM Criteria.
How long do I have to request a Carelon reconsideration?+
In the handbook version we reviewed, three business days from receiving the notice when a medical-necessity denial was issued without a peer-to-peer conversation. Check the current handbook and the denial letter, which control.
Which ASAM edition does Carelon use?+
As of September 2026, Carelon's Medical Necessity Criteria page names The ASAM Criteria for substance use services without stating an edition. Ask the reviewer which edition was applied and organize your evidence by that edition's dimensions.
Can we bill the member while a Carelon appeal is pending?+
The handbook says the provider may not bill or charge the member until all appeals available to the member have been exhausted and the member agrees in writing to pay for non-certified services. Check your contract and state law as well.
Practical closeout
Use this operator checklist.
- Route Anthem requests through Availity under the Anthem payer ID; other Carelon-managed plans use payer ID BHOVO to reach ProviderConnect or eServices.
- Carelon applies CMS coverage documents for Medicare, then custom criteria, then ASAM for substance use and InterQual for mental health, with MCG on some plans.
- In the handbook we reviewed, a denial issued without a peer-to-peer can be reconsidered within three business days of the notice.
- Handbook defaults allow 180 days for a Level I appeal and 90 days for Level II, but plans, states, and CMS programs override them.
- The handbook's 14-day CMS decision window predates CMS-0057-F; Medicare Advantage and Medicaid standard decisions are now due in 7 calendar days.
Continue through the cluster
Verified customer case studies are added only with customer permission and supporting evidence; none is implied by these operational examples.
Sources & methodology
Trace the operational claims.
Marsa Health Editorial reviewed the primary and research sources below on September 21, 2026. We translate them into workflow controls, distinguish proposals from final rules, and flag where plan, program, state, contract, or clinical requirements vary.
- 01Medical Necessity Criteria Carelon Behavioral HealthCarelon's criteria decision order (CMS, custom, ASAM, InterQual, national criteria), MCG use for some plans, the New York continued-stay rule, and criteria availability on request. Retrieved September 2026.Accessed or rechecked September 21, 2026
- 02Provider Portals Carelon Behavioral HealthPortal routing: Availity under the applicable Anthem payer ID for Anthem plans, and Availity under payer ID BHOVO for ProviderConnect or eServices on other Carelon-managed plans.Accessed or rechecked September 21, 2026
- 03Carelon Behavioral Health Provider Handbook (last updated March 1, 2023) Carelon Behavioral HealthThe most detailed Carelon national handbook we could retrieve in September 2026: authorization pattern, determination timeframes, peer review, reconsideration, and appeal defaults. Check the current edition before relying on any timeline.Accessed or rechecked September 21, 2026
- 04Provider Handbook Carelon Behavioral HealthLanding page that links the current Carelon Behavioral Health Provider Handbook, which controls over older versions.Accessed or rechecked September 21, 2026
- 05Streamlining Behavioral Health Authorizations via Availity Essentials Anthem Blue Cross and Blue Shield (Connecticut Provider News)July 1, 2025 notice for Anthem commercial and Medicare Advantage: submit behavioral health authorizations through Availity Essentials beginning August 1, 2025.Accessed or rechecked September 21, 2026
- 06Carelon: Integrated Healthcare Elevance HealthElevance Health's description of Carelon as its healthcare services brand and of Carelon Behavioral Health as formerly Beacon Health.Accessed or rechecked September 21, 2026
- 07CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) Fact Sheet Centers for Medicare & Medicaid ServicesImpacted payers, 72-hour expedited and seven-calendar-day standard decision timeframes (not applicable to FFE QHP issuers), specific denial reasons beginning in 2026, and January 1, 2027 API requirements.Accessed or rechecked September 21, 2026
- 0829 CFR 2560.503-1: Claims Procedure Legal Information Institute (Cornell Law School)Federal claims rule for ERISA group health plans: 72-hour urgent and 15-day pre-service decisions, 24-hour urgent concurrent extensions, and at least 180 days to appeal.Accessed or rechecked September 21, 2026
Organizational author. Editorial review covers source accuracy, search intent, workflow boundaries, and human-oversight requirements. This material is educational and does not provide clinical, legal, coding, or coverage advice.
No named clinical or legal expert reviewer is attributed to this version. Marsa Health does not invent reviewer credentials.
Read our editorial methodRevision history
What changed and when
September 21, 2026
Initial publication, source review, and operational editing.