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Preapprovals (preauthorization)

About preapproval reviews


Wellpoint requires preapproval (preauthorization) review for some services for non-Medicare members. Depending on the service, preapproval reviews are performed by:



Wellpoint Managed Care 


Carelon Medical Benefits Management 




CVS Caremark 


The Provider Reference Sheet lists the services and procedures that require preapproval, what the review requirements are, and who performs each type of review.

Reviews by Wellpoint Managed Care


Wellpoint’s Managed Care department reviews many types of surgery, behavioral health services, and other services and procedures, as listed in the Provider Reference Sheet.

Supporting materials

Reviews by Carelon Medical Benefits Management (CMBM)


Carelon Medical Benefits Management (CMBM) is a Wellpoint-affiliated company that provides support for the preapproval process. The Provider Reference Sheet lists all services reviewed by CMBM.


Carelon Medical Benefits Management’s web-based provider portal application lets providers submit review requests. Often, the entire review and approval process can be done online.  Providers who are already registered for the application do not need to re-register for Wellpoint.

Post-Claim Clinical Appropriateness (PCCA) review

CMBM also handles Post-Claim Clinical Appropriateness (PCCA) reviews for radiology, sleep, genetic testing, and radiation oncology CPT codes. Cases for PCCA review must be more than two business days old, but no more than two years (730 days) old. To initiate a case, you must provide the following information:

  • Member information (Name, DOB, Patient HCID#)
  • Claim number
  • Date of service
  • CPT codes
  • Diagnosis codes
  • Medical records

Reviews by CarelonRx


CarelonRx reviews certain infused (non-oncology) specialty drugs. For non-Medicare Wellpoint members receiving infusions in a hospital outpatient setting, CarelonRx will perform an expanded review for both the drug’s clinical appropriateness and the level of care/site of service.

Reviews by CVS Caremark


CVS Caremark, the prescription drug administrator for non-Medicare Wellpoint members, covers and dispenses self- or office-administered specialty drugs. Some of these specialty drugs require review and dispensing by CVS Caremark.