Updated Utilization Management Requirements for Cardiac Rehabilitation, Musculoskeletal and Gastroenterological Procedures
October 1, 2025 Update: The effective date for musculoskeletal (MSK) inpatient prior authorizations has changed. Prior authorizations for these inpatient codes will be required for services on or after November 10, 2025. The effective date for all other services listed below remains unchanged. Providers can begin to enter prior authorization requests for services starting on October 8, 2025.
At CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (collectively, CareFirst), we’re expanding our collaboration with EviCore to provide a new, simplified prior authorization process for cardiac rehabilitation, gastroenterology and musculoskeletal services.
These updates apply to members enrolled in fully insured commercial plans.
What's Changing
Starting October 8, 2025, providers will be able to submit prior authorization requests for services scheduled on or after October 22, 2025.
Please access the EviCore Resource Page for CareFirst and navigate to the Solutions Resources tab for more information on the specific services requiring authorization. Additional information, such as training resources, clinical guidelines and FAQs will be added as they become available.
Why It Matters
Our goal is to support providers in delivering safe, effective and timely care. Prior authorization helps:
- Avoid unnecessary or duplicative procedures
- Ensure treatments follow national clinical guidelines
- Trigger additional support services like care management or expert consults when needed
Most decisions are made quickly—nearly 90% within just a few hours when all required documentation is submitted with the initial request—so you can move forward with care plans confidently.
Evidence-Based Support
EviCore’s process is grounded in evidence-based clinical guidelines. This ensures that care recommendations are aligned with best practices—while respecting your clinical judgment.
How to Submit Requests
Log into the CareFirst Provider Portal (CareFirst Direct):
- Select the Prior Auth/Notification tab.
- Choose Start under the Cardiology/Radiology/Gastroenterology/Musculoskeletal section to access EviCore’s Prior Authorization Portal.
Training and Support
Live webinars are available to help providers prepare. Each session lasts about one hour and requires advance registration.
Date |
time |
|
|---|---|---|
|
10/02/2025 |
10 to 11 a.m. |
|
|
10/16/2025 |
10 to 11 a.m. |
|
|
10/22/2025 |
1 to 2 p.m. |
|
|
10/23/2025 |
10 to 11 a.m. |
Important Reminders
Services listed that require prior authorization will be denied if performed without it. Participating providers may not seek reimbursement from members for these services.
These changes do not apply to:
- Federal Employee Program (FEP) (‘R’ prefix)
- Federal Employee Health Benefit Plan (Group ND50 and Group ND51)
- Medicare Advantage (‘MXJ’ or ‘EGE’ prefixes)
- CareFirst CHPMD (MDD prefix)
- Advantage DualPrime (DNP MD prefix)
- Non-Risk/Self-Funded Accounts
More information about this initiative will be available in the October issue of BlueLink.