AL
Carve-Out Tracking
Manage delegated services, excluded CPT codes, and vendor assignments for carved-out benefit lines
6
Active Carve-Outs
284K
Members Affected
1
Expiring within 90 Days
3
Vendors Under Contract
Service Line Vendor / TPA Effective Date Term Date Members Status Actions
Mental Health & SUD
Outpatient + Inpatient MH/SUD
Magellan Health
NPI: 1234567890
 01/01/2023 12/31/2025 84,200 Active
Vision Services
Routine eye exams + hardware
EyeMed Vision Care
NPI: 2345678901
 01/01/2024 12/31/2026 71,450 Active
Dental Benefits
Preventive, basic, major, ortho
Delta Dental of CA
NPI: 3456789012
 07/01/2022 06/30/2025 68,900 Expiring
Pharmacy Benefits (PBM)
Retail, mail order, specialty Rx
Express Scripts
NPI: 4567890123
 01/01/2023 12/31/2025 284,100 Active
Durable Medical Equipment
Wheelchairs, oxygen, CPAP
Rotech Medical
NPI: 5678901234
 04/01/2023 03/31/2026 12,340 Active
Behavioral Health (ABA)
Applied Behavior Analysis — autism
Autism Spectrum Therapies
NPI: 6789012345
 01/01/2024 12/31/2025 3,110 Active
AI Assistant

A carve-out is a benefit line delegated to a specialized vendor (TPA or ASO). The health plan does not adjudicate those claims — the vendor handles them directly and returns encounter data.

  • Click any row to view delegated services and excluded CPTs
  • Use Add Carve-Out to configure a new delegation
  • Monitor expiring contracts in the amber "Expiring" badge rows

Excluded CPT codes are denied by the plan's adjudication engine and forwarded to the vendor. Keep this list current — incorrect routing causes coordination failures and member complaints.

Contracts expiring within 90 days are flagged amber. Initiate renewal 120 days before term date to avoid coverage gaps. Network disruption notices must go to members 60 days in advance.

  • Encounter data reconciliation runs monthly — view via Reconciliation Report
  • EDI 837P/I from vendor must arrive within 30 calendar days of service
  • Member counts refresh nightly from the eligibility system