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 Network^SM (BlueHPN^SM) members have limited benefits at the University of Maryland Medical System Downtown Campus.

Ambulance - elective air transport only (10.0.005)
Artificial Cervical Disc (7.01.100)
Artificial Insemination (4.02.009)
Behavioral Health and Substance Use Disorder (Milliman Care Guidelines)
- Applied Behavioral Analysis (ABA)
- Electroconvulsive Therapy (ECT)
- Repetitive Transcranial Magnetic Stimulation (TMS)
- Inpatient Behavioral Health and Substance Use Disorder
- Residential Treatment Centers (RTC)
Clinical Trials (10.01.001A)
Cosmetic and Reconstructive Surgery (7.01.017)
Durable Medical Equipment over specified dollar amounts (varies)
FEP – Medications requiring online prior authorization
Gender Reassignment Services (7 .01.123)
General anesthesia for dental care (9.01.007A)
Genetic testing (11.01.073)
Habilitative Services (8.01.011A)
Home health care (Criteria defined in the employer group benefit contract)
Home Infusion Therapy (Criteria defined in the employer group benefit contract)
Hospice (Criteria defined in the employer group benefit contract)
Hyperbaric Therapy (2.01.004)
IMRT (6.01.038)
Inpatient hospital care (Modified AEP)
Inpatient rehabilitation (Apollo Managed Care Physical Therapy, Occupational Therapy and Rehabilitation Care)

Intravenous Immune Globulin (IVIG) Therapy (5.01.013)
In Vitro Fertilization (4.02.001)
Maternity Services - inpatient only, for stay greater than 48/96 hours (Criteria defined in the employer group benefit contract)
Medications (Drug Policies/Criteria)
Morbid Obesity (7.01.036)
Out-of-network services (Benefits available according to the member contract)
Pre-implantation Genetic Testing (4.02.007)
Private Duty Nursing (Criteria defined in the employer group benefit contract)
Proton Beam Radiation Therapy (6.01.019)
Provenge (2.03.013)
Rehabilitation Therapy
Sclerotherapy* (7.01.082)
Septoplasty* (7.01.017)
Skilled nursing facility admissions (Apollo Managed Care Physical Therapy, Occupational Therapy and Rehabilitation Care)
Sleep Studies (Attended) (2.01.018)
Stereotactic Radiosurgery (6.01.010)
Stereotactic Radiosurgery Using Gamma Rays (6.01.043)
Surgery on the jaw (7.01.022)
Synagis (5.01.019)
Temporo mandibular joint surgery (2.01.021)
Transplants
Uvulopalatopharngoplasty (2.01.018)

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.