A prior authorization, or pre-certification, is a review and assessment of planned services that helps to distinguish the medical necessity and appropriateness to utilize medical costs properly and ethically. Prior authorizations are not a guarantee of payment or benefits.
How do I submit an authorization?
Prior authorization requests should be submitted electronically using the CareFirst BlueCross BlueShield Provider Portal (CareFirst Direct).
- Log into https://provider.carefirst.com
- Select the Prior Authorization/Notifications tab
- Select ‘Start’ with the ‘Medical’ box
- For step-by-step instructions, access the following resources:
Our medical prior authorization system automatically triggers MCG guidelines and requires providers to complete additional information depending on the combination of the diagnosis and procedure codes. Maryland Medicaid inpatient reviews leverage MCG's Inpatient Care Guidelines. Access detailed information on MCG's Care Guidelines.
What services require a prior authorization?
- Utilize the Prior Authorization Lookup tool available on the CareFirst BlueCross BlueShield Provider Portal to verify requirements. Access the Prior Authorization Lookup Tool Walk-through for step-by-step instructions.
- Review the Prior Authorization Guidelines for detailed information on prior authorization requirements.
- Inpatient and Observation Care Admissions Authorization Requirements for Facilities
- Level of Care Review Policy for Facilities
Access the Payment Policy Database located on the CareFirst provider website for information on the following payment policies related to prior authorizations:
Medical Drug Prior Authorizations
CareFirst CHPMD will require prior authorization on certain medical drugs. Prescribers must complete the entirety of the medical injection preauthorization request form with supporting medical documentation and send to CareFirst CHPMD to render medical necessity coverage determination. Failure to do so will result in non-payment. You will not be reimbursed without an approved prior authorization.
Important Information
- The Authorization Guidelines document is not all inclusive.
- All inpatient services require authorizations.
- All outpatient services and procedures by a non-par facility or non-par provider require an authorization.
- Authorization is not a guarantee of payment.
- All authorizations are subject to eligibility requirements and benefit plan limitations.
- Authorizations are issued for medical services assuming that providers submit claims with codes billable under the current Medicaid Fee Schedule.
- Verification of eligibility and/or benefit information is not a guarantee of payment.
- Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of coverage applicable on the date services were rendered.