providers
Medical Pre-Authorization
Prior Authorization Form
Requests for Pre-Authorization should be submitted to:
- Utilization Management Authorization: (202) 821-1132
- Utilization Management Fax Number: (202) 905-0157
Notification of Pregnancy Related Care
Prior Authorization is not needed for Pregnancy related care, however notification is required. You may fax the OB Prior Authorization form to the CM department at (202) 821-1098. The OB/GYN is responsible for notifying the CareFirst CHPDC/Alere Case Manager at (202) 821-1100 for assistance with support services needed to help the pregnant enrollee during pregnancy. Any high-risk pregnancies due to physical, social or behavioral conditions must be reported to CareFirst CHPDC at the time of the first visit or at the time when the high-risk situation develops during the pregnancy. All high- risk conditions should be reported to the high-risk obstetrical case manager. The case manager can be contacted via phone (202) 821-1100. The high-risk case manager partners with the OB practitioner to provide reinforcement education for the high-risk condition and coordinate services needed. For high-risk situations that require consultation and/or management of a perinatologist, practitioners should contact the high-risk case manager at the number above. She/he will help the enrollee to contact the perinatologist for consultation and/or transition management.
CareFirst CHPDC Prior Authorization List
Services that require prior authorization are listed below. Providers can submit requests electronically through the provider portal.
CHPDC Prior Authorization List DownloadEffective April 1, 2021
Inpatient
- Elective inpatient services
- Urgent inpatient services
- Non-participating providers
- Long-term acute hospitalization
Observation Care Admission
- Observation greater than 48 hours
Ambulance
- Elective air transportation only
- Elective non-participating providers
Abortions
- Elective abortions
Auditory Treatment
- Cochlear Implantation
Behavioral Health
- Residential Treatment
- Intensive Day Services Programs
- Inpatient Mental Health
- Inpatient Substance Abuse
- Acute Residential
- Partial Hospital Program
- S O A P Half Day
- Intensive Outpatient Program
Clinical Trials
- Clinical Trial requires prior authorization and medical director review.
Cosmetic Services
(This is not an exclusive list)
- All cosmetic services.
- Breast Reconstruction Surgery
- Chemical Peel
- Dermabrasion
- Ear piercing
- Eyelid and Eyebrow surgery (ptosis repair)
- Excessive Skin removal
- Liposuction
- Nose revision
- Repair nasal septum
Dental Procedures
- Dental procedures are managed by Avesis. Contact Avesis to determine if the procedure requires prior authorization.
DME
DME $750 and greater will require prior authorization. In addition, the following requires prior authorization.
- Semi and total electric hospital bed
- Powered pressure-red air mattress
- Air elevator for heel
- Stationary compressed gas system, purchase
- Portable gaseous oxygen system, rental
- Hi Frequency chest wall oscillator system
- Respiratory suction pump, home model, portable or stationary, electric
- Continuous airway pressure device
- Hospital grade electric breast pump
- Patient lift hydraulic
- Pneumatic compressor, segmental home model without calibrated gradient pressure
- Pneumatic compressor, segmental home model with calibrated gradient pressure
- Segmental pneumatic appliance for use with pneumatic compressor, full leg
- Segmental pneumatic appliance for use with pneumatic compressor, full arm
- Osteogenesis stimulator, electrical, non-invasive, other than spinal applications
- Osteogenesis stimulator, electrical, non-invasive, spinal applications
- Negative pressure wound therapy electrical pump, stationary or portable
- durable medical equipment unlisted codes
- Non-Inhalation Drug for DME
Experimental and Investigational Therapy and Treatment
All experimental and investigational treatment requires prior authorization
Genetic Testing
Genetic Testing requires prior authorization except Spinal Muscular Atrophy. The following requires prior authorization and the list is not inclusive.
- BRCA Gene Testing
- Cytogen Neoplasia Microarray
- Palb Full Gene Seq
- Genome Sequence Analysis
- Genome Sequence Analysis =- Each Comparator
- Inherited Cardiomyopathy Seq Ana
- Whole mitochondrial genome
- Whole MC Genome Lg Dup/Del
- FGFR Gene Analysis
- IDH2 Common Variant
- AOC Gene Full Sequence
- AOC Gene Dup/Delet Variants
- Calr Gene Com Vriants
- CFTR Gene Com Variants
- Cytogen M Array Copy NO & SNP
- F9 Full Gene Sequence
- HBA1/HBA2 Gene
- JAK2 Gene
- KRAS Gene Addl Variants
- MLH1 Gene Full Seq
- MSH2 Gene Full Seq
- MSH6 Gene Full Seq
- Microsatellite Instability
- MECP2 Gene Full Seq
Genetic Testing (Continued)
- PCA3/KLK3 Antigen
- PMS2 Gene Full Seq Analysis
- PMS2 Gene Dup/Delet Variants
- PTEN Gene Full Sequence
- HLA I Typing Complete LR
- Mopath procedure level 3, 5, 6, 7, 8, 9
- Ashkenazi Jewish Genetic Disorders Sequencing
- Cardiac ion channelopathies
- Exome Reveal Proban
- Exome Reveal Trio
- Fetal Chromosomal Aneuploidy, genomic sequence analysis
- Hereditary breast cancer-related disorders
- Hereditary colon cancer
- Hereditary colon syndrome
- Hereditary Neuroendocrine Tumor Disorder
- Inherited Cardiomyopathy
- Genetic Testing for Severe Inherit Conditions
- Targeted Genomic Seq Analysis
- Whole Mitochondrial Genome
- Whole Mitochondrial LG Dup/Del
- Unlisted Molecular Pathology
- Prosigna Breast Cancer Prognostic Gene Signature Assay
- Metamark/Promark
- Genetic Testing for Retinoblastoma
Gender Reassignment
- Gender Reassignment Surgery
Home Health Services
Home health services after the 18th visit requires prior authorization. Personal care aides (PCA) require prior authorization. See Personal care aide. Skilled nursing service to supervise PCA does not require prior authorization.
Hospice
Hospice Care in a Facility
- Acute Hospital and Acute Rehab
- Long term care-skilled facility
Infertility Treatment
All infertility treatment for male and female require prior authorization.
Injections
- Epoetin
- Leuprolide acetate
- Natalizumab Injection
- Omalizumab Injection
- Ranibizumab Injection
- Rituximab
- Synagis (palvizumab)
- Drugs unclassified
Laboratory Testing
- Respir Pathogen 20 Targets
- GI Pathogen 22 Targets
- Thyramir
Non-Participating Provider
Any nonparticipating provider service requires prior authorization.
Outpatient Services
- Hyperbaric Oxygen Therapy
- Supervised Sleep Study
Obesity Treatment
- Obesity Surgery
Personal Care Aide
- Personal Care Aide services require prior authorization.
Prosthetics and Orthotics
Any cost $750 or greater will require prior authorization. In addition, the following requires prior authorization.
- Below knee, molded socket, shin, sach foot. Orthotic and Prosthetic Procedures, Devices
- Below knee, molded socket, shin, sach foot, endoskeletal system. Orthotic and Prosthetic Procedures, Devices
- Addition to lower extremity, below knee, flexible inner socket, external frame. Orthotic and Prosthetic Procedures, Devices.
- Addition to lower extremity, below knee suction socket.
- Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket
- Replacement, socket, below knee, molded to patient model. Orthotic and Prosthetic Procedures, Devices.
- Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation
- Addition, endoskeletal system, below knee, flexible protective outer surface covering system. Orthotic and Prosthetic
- Flex = Foot System
- Flex-walk Sys Low Ext Prosthetic
- Multi-axial rotation unit
- Shank Ft w vert load pylon
Proton Therapy
Proton therapy requires prior authorization
Radiology and Cardiology Procedures
High tech radiology and cardiology procedures done as an outpatient require prior authorization by NIA. The list is not inclusive:
- MRI/MRA, CT scans, PET scan
- TEE, Stress Echocardiography, CT angiogram
Spinal Surgery
- Artificial Disc Replacement
- Cervical Laminectomy
- Spinal Surgery and fusion
Transplant
All transplant surgery
Unlisted codes
- All unlisted codes require review.
- All cpt codes ending in 99
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