Premera to Launch Imaging Clinical Site of Service Program

Premera Blue Cross will launch a new advanced imaging clinical site of service program, effective January 1, 2026. This initiative is designed to optimize health outcomes, manage costs, and improve access to high-quality imaging services for Premera individual and group members.

Here’s what providers need to know to prepare for upcoming changes to imaging site of service reviews in 2026:

Program Overview

Carelon Medical Benefits Management, an independent company, will provide site of service reviews on behalf of Premera. These reviews will focus exclusively on CT and MRI imaging services performed in outpatient hospital settings. Please see the special notice (effective January 1, 2026) on the Medical Policy and Coding Updates web page for more information.

How the Review Process Works

Carelon will evaluate clinical imaging orders using their site of service guidelines to determine medical necessity for performing the service in a hospital-based outpatient setting.

If a request doesn’t meet the medical necessity criteria, an adverse determination may be issued. Providers will have the opportunity to participate in a peer-to-peer discussion with a Carelon reviewer either before or after a determination is made.

For requests deemed medically necessary, Carelon will further review the clinical criteria to determine whether the imaging service truly requires a hospital-based outpatient setting, or if a freestanding imaging center is a clinically appropriate and available alternative. When appropriate, providers and members will be redirected to a freestanding imaging center.

Registration for Providers

Carelon uses OptiNet, an online self-reporting tool available through the Carelon Provider Portal, to support site of service reviews. We’ll be sending registration information to freestanding imaging center providers who will be required to complete the OptiNet registration process.

Registration gives Carelon details on facility, physician, and technician qualifications, as well as accreditation and equipment. With this information, Carelon can establish accurate records and make informed decisions about care, services, and transparency.

Support and Additional Questions

Providers with questions can contact the Premera Physician and Provider Relations team by emailing Provider.Relations@Premera.com.