The Carelon prior authorization form is a one-page fax request used to ask a health plan for approval of an outpatient procedure or diagnostic service before it is performed. The version most providers search for is titled "Preauthorization/RQI Request Fax Form" and lists Carelon Medical Benefits Management, with a fax number of 800-610-0050. Most plans now prefer online requests through the Carelon ProviderPortal, and the right route depends on the plan, the state and the type of service.

This guide shows how to complete the form, which Carelon unit handles medical, therapy, equipment and drug requests, the verified contact routes by plan, and what the 2026 federal prior authorization rules do and do not change. Last checked against the payer pages listed at the end in October 2026.

Key 2026 point: under CMS-0057-F, Medicare Advantage, Medicaid and CHIP plans must decide standard prior authorization requests within 7 calendar days and expedited requests within 72 hours from January 1, 2026, and covered payers must give a specific reason for any denial. Commercial and employer plans are not covered by that rule. See the table below.

Carelon prior authorization form at a glance

Which Carelon route do I need?

"Carelon" is several businesses. The form above is for medical-benefit requests. Therapy, equipment and pharmacy requests can follow different paths. Use the finder, then confirm details with the patient's plan.

Carelon contact routes by plan

These numbers come from the payers' own provider pages. A number that works for one plan is not a universal Carelon line, which is why the same fax or phone number should not be copied onto another plan's request.

Practices that check benefits first can see whether an authorization is needed before the patient arrives. See our guides to insurance eligibility verification and real-time eligibility checks.

Carelon Prior Authorization Form Step-by-Step Instructions

1. Download the right form

Download the Carelon request form or open the request in the portal. Use the fillable PDF if you must fax, because it removes handwriting errors. Before faxing, check your plan's page for a newer version, since the PDF carries no date.

2. Decide the submission route

Use the portal when your plan offers it. Call for urgent requests, as the form instructs. Where a plan restricts fax to existing requests (BCBS Texas) or requires electronic submission (Michigan commercial), a fax will not start a new request.

3. Enter subscriber and patient details

Use names exactly as on the insurance card, the full member ID including any prefix, date of birth in MM/DD/YYYY, the relationship to the subscriber, plan name, group number and product type (PPO, POS or HMO).

4. Add referring physician details

Include the physician's full name, specialty, current phone and fax numbers, and practice address with suite number.

5. Add provider and facility details

Give the name, contact numbers and street address of the facility where the service will be performed.

6. Describe the procedure

Enter the planned date (or a target window), a description with the body area and technique, and the CPT code with any modifiers. Our physical therapy CPT codes reference sheet helps with therapy codes.

7. Complete the clinical information

This section carries the medical justification. State symptom onset, frequency and intensity, effect on daily activity, the purpose of the service, treatments already tried with outcomes, prior test results and, for injuries, the date and mechanism. Strong notes come from clean SOAP documentation.

8. Verify, submit and keep a copy

Check every field and attach supporting records. Submit by your chosen route, keep a copy and note the date and reference number. Then track status in the portal or by phone.

Carelon prior authorization for physical therapy

Several Blue plans run therapy authorization through the Carelon rehabilitation program. It covers physical, occupational and speech therapy, and the Blue Cross NC notice states that authorization requirements are based on the CPT code filed. Blue Cross NC applied the program to fully insured commercial members from December 2024 and to ASO groups from July 1, 2025, and excludes autism spectrum disorder diagnoses.

The Healthy Blue NC program guide adds useful operating detail: the first and second treatment requests can be approved at submission without a documentation upload, the third and later requests need clinical documentation uploaded, a request can name up to two functional outcome tools when more than one body part is treated, and requests that meet criteria receive a response immediately in the portal or by phone. Visits authorized depend on the patient's clinical circumstances. These are North Carolina program rules, so confirm what your own plan requires.

2026 prior authorization rules: what changed and who is covered

The CMS Interoperability and Prior Authorization final rule (CMS-0057-F) sets new requirements for specific payers. The CMS fact sheet lists them as Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and Qualified Health Plan issuers on the federally facilitated exchanges. It states that commercial and employer plans are not covered, and the rule does not apply to drug prior authorizations.

Some states add their own prior authorization rules, so check state law as well. For more detail, read our guide to the CMS 72-hour prior authorization rule.

Automating prior authorization in your practice

The slowest parts of prior authorization are finding out that one is needed, re-typing documentation, and tracking expiry dates. A prior authorization workflow built into your EMR and billing software can address each of them. Try the prior authorization calculator to estimate the staff time your practice spends, or book a demo.

Frequently asked questions

What is the Carelon prior authorization form?

It is the Preauthorization/RQI Request Fax Form for Carelon Medical Benefits Management. Providers use it to request approval of an outpatient procedure or diagnostic service before it is performed. Many plans now require or prefer the online ProviderPortal.

What is the Carelon fax number for prior authorization?

The form lists 800-610-0050. BCBS Texas limits that fax to clinical information for requests that already exist, and Michigan commercial requests must be electronic, so confirm the route for your plan first.

Is Carelon the same as CarelonRx?

No. Carelon Medical Benefits Management handles medical-benefit utilization management. CarelonRx is a pharmacy company, and drug prior authorizations follow the plan's pharmacy process rather than this form.

How do I get prior authorization for physical therapy through Carelon?

Where your plan uses the Carelon rehabilitation program, request through the ProviderPortal or the plan's portal link, or call the plan's Carelon number. Blue Cross NC lists 1-866-455-8414 and Healthy Blue NC lists 1-866-745-1788. Requirements are based on the CPT code filed.

Who handles Carelon durable medical equipment authorization?

For certain Anthem plans, Carelon Post-Acute Solutions handles it, with phone 1-844-411-9622, fax 1-833-311-2986 and the NexLync portal, per an Anthem Ohio provider notice. Other plans use other contacts.

How long does a Carelon prior authorization take?

It depends on the plan and the request. In the Healthy Blue NC program, requests that meet criteria get an immediate response in the portal or by phone. For Medicare Advantage, Medicaid and CHIP plans, the 2026 federal rule sets 72 hours for expedited and 7 calendar days for standard decisions.

Can I submit several procedures on one Carelon form?

The form has one procedure section and the sources reviewed do not state a limit on codes per request. Check the portal or your plan, and request separate authorizations where the plan requires them.

How do I check the status of a Carelon authorization?

Log in to the Carelon ProviderPortal (or the plan's Availity link) and look up the request, or call the plan's Carelon number. Keep the reference number from submission.

Is Carelon the new name for AIM Specialty Health?

Yes. AIM Specialty Health became Carelon Medical Benefits Management in 2023. The portal and inbound phone numbers stayed the same, according to BCBS Texas.

Sources and further reading

• Carelon Preauthorization/RQI Request Fax Form (PDF)
• Blue Cross Blue Shield of Texas: Carelon Medical Benefits Management
• Blue Cross Blue Shield of Michigan: Carelon FAQ for non-drug requests
• Blue Cross Blue Shield of Texas: AIM Specialty Health to Carelon FAQ
• Blue Cross NC: Carelon rehabilitation program for ASO plans
• Healthy Blue NC: Carelon rehabilitation program provider guide
• Healthy Blue NC: new Carelon rehabilitation program notice
• Anthem provider news: DMEPOS authorizations through Carelon Post-Acute Solutions
• CMS: Interoperability and Prior Authorization final rule (CMS-0057-F) fact sheet
• 42 CFR 422.568: standard organization determinations
• 42 CFR 422.572: expedited organization determinations
• Carelon ProviderPortal

This guide is informational and is not legal or payer-specific advice. Contact numbers and requirements change, so confirm them with the patient's health plan before submitting.