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

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.

Advanced Imaging for Cardiology and Radiology Outpatient Prior Authorizations: CareFirst and EviCore Health have collaborated to provide services for CareFirst members enrolled in our fully insured commercial plans for Cardiology and Radiology Advanced Imaging. Please access the 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.


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.

Medicare Advantage

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

Maryland Medicaid Managed Care Organization (MCO)

Refer to the CareFirst Community Health Plan Maryland website for information on submitting a prior authorization for these members.

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