Authorization Process & Forms
CareFirst CHPDC strives to deliver our local Washington DC providers all the resources they need in order to assist them in providing most efficient and effective treatments. The list of authorization and request forms below is meant to assist you with that process. If there is a form that you feel other providers would find useful to access on this page, please contact us at (202) 821-1145.
How Do I request an Authorization?
Pre-Service Authorization requests can be faxed to: (202) 905-0157. Requests for services will be reviewed by experienced Nurses utilizing InterQual criteria and/or other relevant clinical practice guidelines.
- Urgent concurrent Authorization decisions will be made within 24 hours of receipt of request for services. Oral notification will be made within 24 hours of the decision.
- Urgent Expedited Pre-service Authorization decisions will be made within 72 hours of receipt of the request for services with a possible extension of up to 14 calendar days. Oral notification will be made within 24 hours of the decision.
- Standard Non-Urgent Preservice Authorization decisions will be made no later than 14 calendar days of receipt of request for services, with a possible extension of up to 14 calendar days. Oral notification will be made within 24 hours of the decision.
- Post service Authorization decisions, as expeditiously as the member's health condition requires and no later than 14 calendar days of receipt of the request for services with a possible extension of up to 14 calendar days. Oral notification will be made within 24 hours of the decision.
Pre-Service Authorization requests for Behavioral Health Services are handled by Beacon Health Options. (855) 481-7041.
Please note: Services rendered in an Emergency Room, Observation Room, Surgery Center or Hospital Inpatient setting are not managed by NIA.
What services require Prior Authorization?
The majority of services offered by THP do not require a Prior Authorization. Wellness care and diagnostic services (such as screenings and labs) require no prior plan notification. Services that do require a Prior Authorization are consistent with other plans. These services include, but are not limited to:
- Inpatient and Outpatient Services
- Rehabilitative Services
- Nursing Home/ Skilled Nursing/Hospice Care
- Major Surgery and General Anesthesia
- Out of Network Providers
- Non Formulary Pharmaceuticals
Emergency Services Notification
Emergency Services and Emergency Transportation do not require a Prior Authorization, but Plan Notification is encouraged as soon as possible.
It is important to complete all relevant information on the Prior Authorization Form. Prior to sending your requests, please be sure that eligibility is checked. Requests will not be processed if they are missing the member number, clinical information, CPT, ICD-10 codes and/or Physician Signatures.
- Medication Prior Authorization Form (PDF)
- Formulary Exception Form (PDF)
- Mavyret PA Request and Required Documentation (PDF)
- Opioid PA Request Form (PDF)
Pregnancy care does not require a Pre-Authorization. However, plan notification of OB services is required. OB care and services will be coordinated by a CareFirst CHPDC OB Case Manager. You may fax this OB Authorization form to UM at (202) 821-1098.