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Meet Carelon: The Company Deciding If Your Care Gets Approved

Who they are, what they have been accused of — in documented legal and regulatory actions — and what to do when they deny you.

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Carelon · Prior Auth · Anthem
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What Carelon Is

Carelon is a medical benefits management company owned by Elevance Health — formerly known as Anthem. Carelon handles prior authorization and utilization management for a large number of health plans. It operates under several names: Carelon Medical Benefits Management (specialty procedures, imaging, surgical approvals), Carelon Behavioral Health (formerly Beacon Health Options — mental health and substance use), and CarelonRx (pharmacy prior authorizations). You may also still see AIM Specialty Health on paperwork — AIM was rebranded as Carelon.

If your insurance is through any Anthem-affiliated Blue Cross Blue Shield plan, Carelon is likely involved in your prior authorization reviews. If your denial letter mentions AIM Specialty Health, Carelon, or Beacon Health Options — Carelon made the call.

The Public Record — Documented Legal and Regulatory Actions
$13 Million Settlement (2022)
Carelon, operating as AIM Specialty Health, settled a lawsuit for $13 million. The lawsuit alleged deliberate techniques to avoid approving legitimate prior authorization requests. One documented allegation: AIM programmed its fax machines to accept only 5–10 pages. When doctors faxed requests longer than the page limit, the company would deny the request for having insufficient documentation. The doctor's records were complete. The fax machine was not. Carelon settled and admitted no fault.
Ghost Network Lawsuit (April 2025)
A class action lawsuit was filed against Carelon Behavioral Health on behalf of more than one million patients in New York's state employee health plan. The lawsuit alleged Carelon published a provider directory listing hundreds of mental health providers who did not actually accept the insurance. Attorneys called 300 doctors from Carelon's own directory — most did not accept the plan. Ghost networks mean patients are told providers are available, cannot find anyone who actually takes their insurance, and are forced to pay out-of-network rates or go without care. Carelon denied the allegations.
Behavioral Health Parity Violations
Carelon Behavioral Health has faced regulatory action in California and lawsuits in multiple states alleging it applied stricter criteria to mental health and substance use claims than to comparable medical care — a violation of the Mental Health Parity and Addiction Equity Act. The California Department of Managed Health Care has received thousands of complaints about Anthem-affiliated plans managed by Carelon.
What to Do If Carelon Denied You
STEP 01
Get the denial in writing with the specific criteria
You are entitled to a written explanation that includes the specific clinical criteria used to deny your request. If you only received a generic letter, call the number on the denial notice and ask for the full criteria document.
STEP 02
Request peer-to-peer review — be persistent
Your doctor can request a peer-to-peer review with a Carelon physician. Many denials are overturned at this stage when the right clinical information is presented. Encourage your doctor to be persistent — there are often time limits, and Carelon can be difficult to schedule with.
STEP 03
File a formal appeal with language that matches their criteria
The appeal must directly address the specific reason cited in the denial, using language that matches Carelon's own criteria. Generic appeal letters rarely work. If the denial cites a specific criterion, your appeal needs to address that criterion specifically with supporting documentation.
STEP 04
Exercise your right to external review
If the internal appeal is denied, you have the right to request an external review by an independent organization. This right exists in every state and under federal law. External reviewers overturn insurance denials at meaningful rates — and Carelon's documented practices make it worth pursuing.
The system is designed to be confusing enough that you give up before you reach the finish line. Most people do. You have more options than you have been told.
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