- CareFirst CHPMD Providers: Starting 11/2, you can submit medication prior authorizations electronically through the CareFirst Provider Portal. For more information watch this recorded webinar or access the step-by-step guide.
- All Providers: Billing NPI Reminder:The billing NPI submitted on claims must match the billing NPI on file with CareFirst,NPPES and MPRIME(CareFirst CHPMD). If your billing NPI is not enrolled with CareFirst, add it here .
Change Healthcare notifying individuals of data breach. Learn more here.
Prior Authorization Requirements Reduced for Commercial BlueChoice HMO and POS Products
We know that time spent managing prior authorizations is time away from your patients. To help ease this administrative burden, effective immediately, CareFirst has reduced prior authorization requirements for many preventive/basic services performed in the outpatient place of service for our commercial BlueChoice HMO and POS products.
Please note that services that otherwise require prior authorization remain subject to existing requirements. Providers should continue to use the Prior Authorization Lookup (PAL) tool to confirm requirements before rendering services.
Why has CareFirst implemented this change?
This change is aimed at helping to simplify workflows, reduce administrative burden and help providers and their teams support more timely access to care for our members.
Which members are impacted by this change?
This change applies to CareFirst’s commercial fully insured (risk) and self-insured (non-risk) BlueChoice HMO and POS products.
Which members are not impacted by this change?
This change does not apply to Medicare Advantage, CareFirst CHPMD, DualPrime, Healthy DC, Federal Employee Program or BlueCard members from other BlueCross BlueShield plans.
Important note: These changes currently do not apply to members in BlueChoice plans that are part of the Federal Employee Health Benefit Plan. These plans are identified as Group ND50 or Group ND51 on member ID cards, eligibility summaries in CareFirst Direct and on the policy detail screen in the Prior Authorization Lookup (PAL) tool. We expect these changes to be implemented for these groups in early 2027.
Where should I go to verify prior authorization requirements?
Providers should continue to confirm prior authorization requirements before rendering services by using the CareFirst Prior Authorization Lookup Tool, available through the CareFirst Provider Portal. This tool remains the best resource to verify whether prior authorization is required based on the member’s plan, product and service details. It also provides you with a searchable history of your verification results when using the tool.
- Need help using the PAL Tool? Access these step-by-step instructions. For additional resources to support you, access the Learning and Engagement Center.
What else should providers know about this change?
- Prior authorizations are not a guarantee of payment or benefits. Authorizations are subject to eligibility requirements, medical necessity, and benefit plan limitations. It is important that you check member eligibility and benefit coverage using CareFirst Direct. For assistance, access our online resource, Checking Eligibility and Benefits in CareFirst Direct.
We appreciate your continued partnership and the care you deliver to our members. CareFirst remains committed to identifying opportunities that ease administrative requirements while supporting timely, appropriate access to care.