Pre-Cert/Pre-Auth (Out-of-Area)

CareFirst BlueCross BlueShield (CareFirst) has put together a quick, simple way to get the information you need in order to assist our CareFirst members.

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

Services Requiring Pre-Service Review

Please view the list below to identify the services that generally require Pre-Service Review (pre-certification/pre-authorization). 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.

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) (3.01.015)
- 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 Affirmation Services/Gender Dysphoria (7.01.123)
General anesthesia for dental care (9.01.007A)
Genetic testing
Habilitative Services (8.01.011A)
Home health care
Hospice
Hyperbaric Therapy (2.01.004)
IMRT (6.01.038)

Intravenous Immune Globulin (IVIG) Therapy (5.01.025)
In Vitro Fertilization (4.02.001)
Certain Medications (Review Pharmacy Prior Authorization webpage)
Morbid Obesity (7.01.036)
Scheduled out-of-network services
Pre-implantation Genetic Testing (4.02.007)
Private Duty Nursing
Proton Beam Therapy (6.01.048)
Rehabilitation Therapy
Sclerotherapy (7.01.082)
Septoplasty (7.01.017)
Sleep Studies (Attended) (2.01.018)
Stereotactic Radiosurgery (6.01.010)
Stereotactic Radiosurgery Using Gamma Rays (6.01.043)
Surgery on the jaw
- Oral-Facial Trauma/Accidental Injury (7.01.136)
- Oral-Facial Pathology (7.01.137)
Temporomandibular joint surgery (2.01.021)
Transplants

How to Obtain Pre-Service Review

If the service you are inquiring about does require a Pre-Service Review, use your local Plan’s Electronic Provider Access (EPA) tool to submit the request. If your Plan does not yet use the EPA functionality, call 1-866-773-2884 or use the forms below to initiate Pre-Service Review.

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