CareFirst’s Annual Care Management Criteria Review is Complete

February 23, 2016 -

CareFirst's Medical Directors and a panel of regional practitioners met in November 2015 to complete the annual criteria review process.

The panel, which included primary care physicians and multiple specialists, reviewed, modified and/or approved the following:

• Appropriateness Evaluation Protocol (AEP) Criteria
• Apollo Managed Care Physical Therapy, Occupational Therapy, and Rehabilitation Criteria
• CareFirst Medical Policy Reference Manual
• The Magellan Behavioral Health 2016 Medical Necessity Criteria
• The Dental Criteria Guidelines

The updated criteria was effective starting Jan. 1, 2016.

As a reminder, CareFirst makes available physician reviewers to discuss utilization management decisions. Physicians may call 410-528-7041 or 1-800-367-3387 x 7041 to speak with a physician reviewer. All cases are reviewed on an individual basis.

Need a copy of the updated criteria and guidelines?

A copy of any of the mentioned criteria can be obtained or reviewed by calling 410-528-7041.

Important Note:

CareFirst affirms that all Utilization Management (UM) decision-making is based only on appropriateness of care and service. We do not reward practitioners or other individuals conducting utilization review for denials of coverage or service.

In addition, financial incentives for UM decision-makers do not encourage denials of coverage or service.