CareFirst Implements Changes to Observation Admission
Update: Notification of observation level of care will no longer be required effective January 1, 2023. All other requirements remain in effect.
At CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (CareFirst), ensuring our members are consistently receiving the right care at the right time and the right level is our priority. Starting January 1, 2023, CareFirst will require notification of an observation admission for all in-network facilities.
This change will apply to your Commercial patients. MCG guidelines are not required for observation notifications, so you may receive a “No Guidelines Apply” message. For assistance utilizing the MCG interface within the authorization system access the ‘MCG Walkthrough Course’.
These notifications of admission to observation level of care should be submitted when observation services start or within seven calendar days of that date. CareFirst will continue to review for medical necessity when claims are submitted.
Important Note for BlueChoice Members: BlueChoice patients already require notification for observation services. These notifications are currently entered as outpatient observation requests. Beginning January 1, 2023, a notification of admission to observation level of care will need to be entered instead for all Commercial patients.
Are there additional changes? Yes, effective January 1, 2023, observation services will be limited to 72 hours, at which time the patient should be admitted or discharged to a lower level of care. MCG guidelines will apply for admission and will be used to review for medical necessity.
Where can I find more information? Additional details and training will be provided as we get closer to implementation, including updates to the provider manual. We will also be covering this topic during our upcoming Hospital Quarterly webinars. Click on one of the sessions below to register. Both sessions will cover the same content.
You can access our full suite of on-demand prior authorization trainings on the Learning and Engagement Center at carefirst.com/learning. Click on the "CareFirst Essentials" link and scroll down to find the applicable Authorization training.