Pre-Cert/Pre-Auth (In-Network)

Medicare Advantage

CareFirst Medicare Advantage requires notification/prior authorization of certain services. This list contains notification/prior authorization requirements for inpatient and outpatient services.

CareFirst Commercial Pre-Service Review and Prior Authorization

View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.

The services marked with an asterisk (*) only require Pre-Service Review for members enrolled in BlueChoice products if performed in an outpatient setting that is on the campus of a hospital. PPO outpatient services do not require Pre-Service Review.

Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Please refer to the criteria listed below for genetic testing.

Contact 866-773-2884 for authorization regarding treatment.

Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus.

Any drugs, services, treatment, or supplies that the CareFirst medical staff determines, with appropriate consultation, to be experimental, investigational or unproven are not covered services. For more information, please refer to the Medical Policy Reference Manual.

CareFirst reserves the right to change this list at any time without notice. CareFirst does not guarantee that this list is complete or current. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884.

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