Change Healthcare Notice

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

What is a Prior Authorization?

A prior authorization, or pre-certification, is a review and assessment of planned services that helps to distinguish the medical necessity and appropriateness to utilize medical costs properly and ethically. Prior authorizations are not a guarantee of payment or benefits.

How do I submit an authorization?

Most prior authorizations are submitted through our CareFirst Provider Portal. You can find training related to prior authorizations on our Learning and Engagement Center at carefirst.com/learning. Select ‘CareFirst Essentials’ under On-Demand Training. Then select any of the accordions labeled ‘Authorizations’ to access the training.

What services require a prior authorization?

Refer to the sections below to determine which services require prior authorization based on product. Click on the links to access the criteria used for Pre-Service Review Decisions.

Prior Authorization Lookup Tool
To verify prior authorization requirements, log into the CareFirst Provider Portal and navigate to the ‘Prior Auth/Notifications’ tab to access the Prior Authorization Lookup (PAL) Tool. Access these step-by-step instructions for assistance.

Medical Policy
To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. 

Clinical Guidelines
Our medical prior authorization system automatically triggers MCG guidelines and requires providers to complete additional information depending on the combination of the diagnosis and procedure codes. Access detailed information on MCG's Care Guidelines.

Other Important Information

Genetic Testing Authorizations: As a reminder, ordering physicians are required to request authorization for molecular genetic tests (see criteria listed below). For step-by-step instructions, access our Genetic Testing Prior Authorization course.

Prior Authorization through EviCore: CareFirst and EviCore are collaborating to provide a simplified prior authorization process for advanced imaging for cardiology and radiology, cardiac rehabilitation, gastroenterology and musculoskeletal services for commercial fully insured members. Please access the CareFirst Resources Page EviCore Health Resource Page for CareFirst for more information on services requiring authorization, clinical guidelines, FAQs, and training opportunities.

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

CareFirst medical staff, with appropriate consultation, reserves the right to not cover certain drugs, services, treatment or supplies that may be experimental or investigational, excluding clinical trials. For more information, please refer to the Medical Policy Reference Manual.

CareFirst will update this list from time to time. Additionally, this list may vary based on account contracts and should be verified by contacting 1-866-773-2884.

BlueChoice

Refer to this section for BlueChoice HMO Members.

Note: Some services rendered in the provider office may not require prior authorization.

PPO Members Only

These services require Pre-Service Review for members enrolled in PPO products.

Inpatient Services

All inpatient services require an authorization for BlueChoice, PPO and FEP, including but not limited to:

  • Inpatient hospital care (MCG Guidelines)
  • Inpatient rehabilitation (MCG Guidelines)
  • Maternity Services - inpatient only, for stay greater than 48/96 hours
  • Skilled nursing facility admissions (MCG Guidelines)

Federal Employee Program (FEP)

Some services require authorization for FEP products. Refer to the table/list in the medical provider manual for services requiring a prior authorization. For medications require prior authorization, refer to the FEP Medication List.

CareFirst BlueCross BlueShield Medicare Advantage

CareFirst BlueCross BlueShield Medicare Advantage requires prior authorization of certain services. Please refer to the Medicare Advantage Prior Authorization Quick Reference Guide for all Medicare Advantage PPO plans and DualPrime Prior Authorization Quick Reference Guide for the Medicare Advantage Dual Special Needs HMO-SNP plan.

CareFirst BlueCross BlueShield Medicare Advantage inpatient reviews leverage MCG's Inpatient Care Guidelines. Please refer to the MCG Care Guidelines link above for more information.

CareFirst BlueCross BlueShield Community Health Plan Maryland

Refer to the Prior Authorization page on the CareFirst BlueCross BlueShield Community Health Plan Maryland website for more information on submitting a prior authorization for these members.

CareFirst BlueCross BlueShield Advantage DualPrime (HMO-SNP)

Refer to the CareFirst BlueCross BlueShield Medicare Advantage DualPrime (HMO-SNP) Prior Authorization Quick Reference Guide for more information on submitting a prior authorization for these members.

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