Virtual Health
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Health Information Network (HIN)
Provides access to patient information including demographics, eligibility and benefits, claims, claim submission, claim correction, claim status, remittance advices, fee schedules, and more.
Learn more about HINCoverage policy
Quickly search for coverage information using a keyword, procedure code, policy number or title.
View coverageValue-based programs
Learn more about our value-based care program, which rewards providers for coordinating care and for positive health outcomes.
View value-based careMedical Pharmacy
Learn more about pharmaceutical therapies administered by a provider and billed through the medical benefit.
Learn more about medical pharmacyInterQual® Coverage Policy Guidelines
The InterQual® guidelines are used by our utilization management team to help assess whether a given medical condition and known or represented circumstances of a case support medical service(s) as the most appropriate treatment, or whether the medical condition/circumstances presented could be appropriately addressed with an alternative treatment. Use the self-registration tool at the link to create a login and view the criteria. Individuals without an email address should contact the plan to receive the criteria information via mail. Please consult your provider for applicable policies and/or criteria.
LoginLucet Medical Necessity Criteria and Request Forms
Lucet Health (Lucet) utilizes medical necessity criteria to make medical necessity determinations. The medical necessity criteria set applied varies according to the behavioral health service being requested. Please consult your provider for applicable policies and/or criteria.
Lucet HealthCarelon Clinical Guidelines
The guidelines are designed to evaluate and direct the appropriate utilization of certain health care services. They are based on data from peer-reviewed scientific literature, criteria developed by specialty societies, and from guidelines adopted by other health providers. Please consult your provider for applicable policies and/or criteria.
Carelon Clinical Guidelines