Prior authorization, sometimes referred to as pre-certification, is a crucial process in healthcare administration. It involves a detailed review of planned medical services to determine their medical necessity and appropriateness. This process is essential for ensuring responsible and ethical utilization of healthcare resources and managing medical costs effectively. It’s important to note that prior authorization is not a guarantee of payment or benefit coverage, but rather a preliminary assessment. While understanding prior authorization is key, healthcare providers must also stay informed about various payer-specific guidelines, including reminders about coding accuracy and comprehensive patient care, such as those related to BMI for certain populations and plans like BCBS FL. This guide focuses on prior authorizations within the CareFirst network.
Submitting a Prior Authorization to CareFirst
CareFirst streamlines the prior authorization submission process through their CareFirst Provider Portal. This online portal is the primary method for submitting most authorization requests. To assist providers in navigating this system, CareFirst offers comprehensive training materials available on their Learning and Engagement Center at carefirst.com/learning.
Alt Text: CareFirst Provider Portal login screen example for submitting prior authorizations.
On the Learning and Engagement Center, navigate to ‘CareFirst Essentials’ under On-Demand Training. Within this section, you will find accordions labeled ‘Authorizations’ that provide access to various training resources. These resources are designed to guide you through the submission process efficiently and accurately.
Services Requiring Prior Authorization from CareFirst
The necessity for prior authorization depends on the specific service and the CareFirst product under which the member is enrolled. Below is a breakdown of services that typically require prior authorization, categorized by product type. For detailed criteria used in Pre-Service Review Decisions, please refer to the provided links.
Medical Policy: For specific medical policies related to each service, click the provided links or search for the policy number in the Medical Policy Reference Manual. This manual serves as a comprehensive resource for understanding CareFirst’s medical policies.
Clinical Guidelines: CareFirst’s medical prior authorization system integrates MCG guidelines. This system automatically triggers these guidelines and may require providers to furnish additional information based on the specific combination of diagnosis and procedure codes submitted. Detailed information about MCG’s Care Guidelines can be accessed at MCG’s Care Guidelines.
Alt Text: MCG Care Guidelines logo representing clinical decision support resources for prior authorization.
Important Information Regarding CareFirst Prior Authorizations
Genetic Testing Authorizations: It is essential to remember that ordering physicians are mandated to request prior authorization for molecular genetic tests. Specific criteria for these tests are outlined below. For step-by-step guidance on this process, CareFirst provides a dedicated Genetic Testing Prior Authorization course.
Advanced Imaging for Cardiology and Radiology Outpatient Prior Authorizations: CareFirst has partnered with EviCore Health to manage prior authorizations for advanced imaging services in Cardiology and Radiology for members in fully insured commercial plans. Visit the EviCore Health Resource Page for CareFirst for comprehensive details on services requiring authorization, clinical guidelines, frequently asked questions, and training opportunities related to EviCore and CareFirst.
Note for Blue High Performance NetworkSM (BlueHPNSM) members: Benefits for BlueHPNSM members are limited at the University of Maryland Medical System Downtown Campus. Providers should verify benefit coverage prior to service.
CareFirst medical staff retain the right, with appropriate consultation, to not cover experimental or investigational drugs, services, treatments, or supplies, with the exception of clinical trials. For further details, please consult the Medical Policy Reference Manual.
It’s important to note that CareFirst regularly updates its list of services requiring prior authorization. Additionally, authorization requirements can vary based on specific account contracts. Providers are advised to verify requirements by contacting CareFirst directly at 1-866-773-2884.
BlueChoice Prior Authorization Guidelines
This section is specifically for services provided to BlueChoice HMO members.
Note: Some services administered within the provider’s office may be exempt from prior authorization requirements. Always verify eligibility and benefits.
PPO Member Prior Authorization Requirements
For members enrolled in CareFirst PPO products, the following services necessitate Pre-Service Review.
Inpatient Services Requiring Authorization
Authorization is mandatory for all inpatient services for BlueChoice, PPO, and FEP members, including but not limited to:
- Inpatient hospital care (MCG Guidelines apply)
- Inpatient rehabilitation (MCG Guidelines apply)
- Maternity Services – inpatient stays exceeding 48 hours for vaginal delivery and 96 hours for Cesarean delivery.
- Admissions to skilled nursing facilities (MCG Guidelines apply)
Alt Text: Depiction of an inpatient hospital setting, highlighting services that often require prior authorization.
Federal Employee Program (FEP) Prior Authorization
Certain services for members with Federal Employee Program (FEP) coverage require authorization. Refer to the detailed table or list within the medical provider manual for a comprehensive list of services requiring prior authorization under FEP. For medication-specific prior authorization requirements, please consult the FEP Medication List.
Medicare Advantage Prior Authorization
CareFirst Medicare Advantage plans have specific notification and prior authorization requirements for certain services. The Medicare Advantage Prior Authorization list details these requirements for both inpatient and outpatient services.
Medicare Advantage inpatient reviews are conducted using MCG’s Inpatient Care Guidelines. Refer to the MCG Care Guidelines link provided earlier for more information on these guidelines.
Maryland Medicaid Managed Care Organization (MCO) Authorization
For providers rendering services to members of the Maryland Medicaid Managed Care Organization (MCO), please visit the CareFirst Community Health Plan Maryland website for specific information on submitting prior authorizations.
Inpatient reviews for Maryland Medicaid also utilize MCG’s Inpatient Care Guidelines. Please refer to the MCG Care Guidelines link mentioned previously for further details.
By understanding and adhering to these prior authorization guidelines, healthcare providers can ensure efficient processing of claims and deliver optimal care within the CareFirst network, while also remaining mindful of broader healthcare considerations including coding accuracy and patient-specific care reminders.
