Specialist Referral Process

Specialist Referral Process

Effective April 1st, 2017 CareFirst CHPDC will no longer require an electronic referral from our participating PCPs for CareFirst CHPDC's enrollees to access specialty services. Our systems have been configured to adjudicate claims without having to look for the electronic referral. However, we are requiring our Primary Care Providers to send the referral information via a letter, prescription or communicate telephonically with the specialist rendering the services. We are also requiring the specialist rendering the services to adhere to industry standards by including the referring PCP's NPI number on their claims.

If a specialty provider is out of network, and the service cannot be provided in-network, a prior-authorization must be obtained.

Case Management / Disease Management Referral Process

CareFirst CHPDC has a robust Case Management/Disease Management Program to coordinate the care for enrollees with high risk or chronic conditions. Please use the referral form below to refer an enrollee to any of the following programs:

• Childhood Asthma
• Renal
• Diabetes
• Cardiovascular
• Respiratory (Asthma and COPD)
• Social Services
• High Risk Pregnancy
• Palliative care
• Multiple admissions
• Multiple Comorbidities
• Pharmacy Review
• Other

Diabetes Disease Management Program

CareFirst CHPDC has a Diabetes Disease Management Program. All CareFirst CHPDC enrollees aged 18+ with a primary or secondary diagnosis of Diabetes or Pre-Diabetes (with the exception of Gestational Diabetes) is eligible to receive the benefits of this program. All eligible enrollees will undergo a Diabetes Health Risk assessment and receive education and services customized to their severity of illness.

Benefits of this program include:

• Disease Management Staff Outreach
• Educational Materials
• Educational Seminars and Services at the Health and Wellness Outreach Center
• Medication and Preventative Health Monitoring
• Case Management Services and PCP outreach and care coordination are also available to High Risk enrollees.

Childhood Asthma Disease Management Program

CareFirst CHPDC has a Disease Management Program for Childhood Asthma. All CareFirst CHPDC enrollees aged 2-20 with a primary or secondary diagnosis of Asthma is eligible to receive the benefits of this program.  All eligible enrollees will undergo an Asthma assessment and receive education and services customized to their severity of illness.
Benefits of this program include:

• Disease Management Staff Outreach
• Educational Materials
• Educational Seminars at the Health and Wellness Outreach Center
• Medication and Preventative Health Monitoring
• Smoking cessation classes and support group

Case Management Services and PCP outreach and care coordination are also available to High Risk enrollees.

If you identify an enrollee that would benefit from either of these services, please contact CareFirst CHPDC at (202) 821-1132, or complete the referral form below.