Carelon and Its Role in Your Health and Health Insurance Claims
Handling a health insurance claim is often challenging, especially when dealing with lesser-known entities like Carelon. If you’re a California consumer whose health insurance claim has been denied, it’s crucial to understand the role companies like Carelon play in managing claims and their relationship with larger insurers, such as Anthem. Below, we delve into what Carelon is, its relationship to Anthem, what consumers should know about having Carelon as part of their health insurance experience, and its history with bad faith lawsuits and regulatory scrutiny. If your health insurance claim has been unfairly denied by Anthem, Carelon, or other insurers, contact Gianelli & Morris in Los Angeles to share your concerns with a leading California insurance bad faith lawyer.
What Is Carelon?
Carelon is a healthcare services company that operates as part of Elevance Health (formerly Anthem, Inc.). Carelon focuses on areas like behavioral health, complex care management, and pharmacy benefits. Its services aim to provide integrated solutions for healthcare delivery, offering support for patients with chronic conditions or complex healthcare needs.
Carelon is not an insurance provider itself but functions as a third-party administrator (TPA) or a service provider for health insurance plans. This means Carelon often processes claims, manages healthcare networks, and coordinates services on behalf of insurers.
Carelon’s Relationship with Anthem
Carelon is a subsidiary of Elevance Health, the parent company of Anthem Blue Cross in California. While Anthem remains the primary health insurance brand, Carelon may handle specific claims or care management tasks. For example, if a California Anthem policyholder requires behavioral health services, Carelon Behavioral Health (formerly Beacon Health Options) might oversee claim approvals or service coordination.
This relationship means that decisions impacting your care—such as claim approvals or treatment authorizations—might involve Carelon, even if your insurance card says Anthem. Understanding this dynamic is essential for effectively addressing claim denials.
What Should Consumers Know About Having Carelon as a Service Provider?
If Carelon is involved in your health insurance plan, there are several critical considerations:
- Transparency Issues: Consumers might not realize that Carelon, not Anthem, is making determinations about their care. This can create confusion when appealing denied claims or navigating pre-authorizations.
- Accountability: Carelon, like Anthem, is subject to oversight by the California Department of Managed Health Care (DMHC). This means they are required to adhere to California laws protecting policyholders from bad faith practices and unreasonable claim denials.
- Behavioral Health Services: If your claim involves mental health or substance abuse treatment, you might deal with Carelon Behavioral Health. Under California’s Mental Health Parity Act, Carelon must cover mental health services at the same level as physical health treatments.
Has Carelon Been Involved in Bad Faith Lawsuits or Regulatory Actions?
Carelon has faced scrutiny and legal challenges, particularly concerning its behavioral health services. Here are some key points about its legal and regulatory history:
- Bad Faith Allegations: As part of its former brand, Beacon Health Options, Carelon Behavioral Health has been accused in lawsuits of improperly denying mental health and substance abuse claims. Plaintiffs have alleged that the company prioritized cost-saving over providing necessary care, potentially violating California’s Mental Health Parity Act.
- DMHC Enforcement: The California Department of Managed Health Care (DMHC) has taken action against health insurers, including Anthem and others working with Carelon, for improper claim denials or failing to provide adequate coverage for behavioral health services. While Carelon may not always be named directly, its role in care determinations puts it under the DMHC’s jurisdiction.
- Settlements and Class Actions: Anthem and its subsidiaries have been defendants in numerous lawsuits, including class actions alleging systematic bad faith practices. If Carelon was involved in administering claims for these plans, its role could be relevant in these cases.
What to Do If You Experience a Claim Denial from Carelon or Anthem
California consumers have robust legal protections against bad faith insurance practices. If Carelon denies your claim, request a written explanation from the company. Under California law, the insurer must provide a detailed reason for the denial. If you believe the denial was made in bad faith—such as ignoring medical necessity or delaying a valid claim—you may have grounds for a lawsuit. An attorney experienced in insurance law can evaluate your case and help hold the insurer accountable.
Carelon’s role in managing health insurance claims adds complexity for California consumers, but it also underscores the importance of understanding your rights. Whether you’re dealing with a mental health claim denial or a broader issue, knowing how to navigate these challenges can make all the difference. If you believe Carelon or Anthem has acted in bad faith, legal recourse may be available to help you recover the benefits you deserve. In California, contact Gianelli & Morris at 212-489-1600 for a free consultation to review your situation and find out how we can help.
