Medical Benefits Management
Where others see complexity, we see the opportunity for a more connected care experience.
What’s possible when care is connected?
Your members and providers face complex decisions every day — from what care is appropriate to where it should be delivered. When those decisions fall outside evidence-based best practices, they can lead to unnecessary care, added risks for your members and organization, and higher costs.
Carelon brings together clinical expertise, technology, and engagement support to address inappropriate care from multiple angles. We help care providers make informed decisions and simplify workflows while providing members with support and transparency around their care. This connected approach is designed to support care outcomes and experiences while helping you manage healthcare costs.
Drive savings with clinical rigor
You have high standards. We do, too. That’s why we’ve spent over 35 years assembling the expertise of more than 370 board-certified physicians and over 1,000 clinicians spanning more than 50 specialties to power our solutions. Because with something as complex as healthcare, experience is an investment worth making.
Our clinical teams help anticipate and address complex challenges while keeping your priorities, member well-being, and provider satisfaction central to our approach. This clinical rigor helps support appropriate care and offers the potential for lower costs for your health plan.
Lay the foundation for best-practice care
From examining social drivers of health to identifying gaps in care, our solutions are designed to do more than redirect care. Depending on the need, we can connect members with wraparound resources like care navigation, health coaching, and in-home assessments. This broader view allows us to deploy solutions that help address fragmentation across the care journey and support a safe, effective, and connected care experience for your members.
Strengthening care outcomes, together
Partnership is central to how we work with health plans. We collaborate with your team to support care outcomes and manage costs while working as an extension of your team in supporting provider relationships and the member experience.
As clinicians and patients ourselves, we understand the importance of making healthcare work better for the people who depend on it.
Scale and experience powering our support
Solutions for your most complex challenges
Every health plan has different priorities. We tailor our solutions to your needs, supporting an end-to-end strategy that is aligned with your priorities while also keeping the needs of your members and providers in focus.
Core Suite
Support high-quality, lower-cost diagnostic and specialty care.
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Radiology
Support timely, evidence-based advanced imaging decisions through clinical review and clear criteria.
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Cardiovascular
Enable appropriate use of cardiac and vascular tests, devices, and procedures through established clinical pathways.
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Sleep
Manage evidence-based sleep care from testing through treatment and monitoring while helping control unnecessary costs.
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Surgical Procedures
Inform surgical care decisions through evidence-based review, provider engagement, and site-of-care optimization.
Musculoskeletal Suite
Help members recover from bone and tissue injuries and disorders through established clinical pathways.
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Musculoskeletal
Support clinically appropriate musculoskeletal care through clinical review, specialty-matched physician consultation, and site-of-care optimization.
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Rehabilitation
Manage physical, occupational, and speech therapy care based on each member’s needs and evidence-based guidelines.
Oncology Suite
Leverage current clinical evidence and best practices to support appropriate oncology care.
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Medical Oncology
Bring together evidence-based clinical guidance and operational support to inform complex and continually evolving cancer care decisions.
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Radiation Oncology
Evaluate radiation therapy requests using evidence-based guidelines, medical policies, and cancer treatment pathways.
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Genetic Testing
Inform appropriate testing through established clinical criteria, expert review, and network alignment.
Post-Acute Suite
Support recovery after hospitalization and help members maintain their quality of life.
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Home-Based Post-Acute
Help improve post-acute recovery with coordinated, clinically appropriate care in the home.
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Facility-Based Post-Acute
Support appropriate facility care with level-of-care review, length-of-stay planning, and safer transitions.
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Durable Medical Equipment
Manage durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) review, delivery, and member education so equipment supports safe, timely recovery.
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Post-Acute Complete
Our Post-Acute Complete solution connects utilization management, care navigation, and care provider collaboration across post-acute settings. It supports safer transitions, more coordinated recovery, and better experiences after hospitalization.
See healthcare from our perspective
Creating a more sustainable health system requires evidence-based clinical decision-making and more connected approaches to complex and post-acute care. See how we are helping healthcare organizations put those approaches into practice.
Frequently asked questions about Medical Benefits Management
Ready to learn more?
We’re here to answer any questions you have about our capabilities.