COVID-19 Prior Auth
Prior Authorization and Concurrent Review Process –
Effective January 5, 2022 – February 15, 2022
The temporary utilization management policies described below apply to all CareFirst lines of business (commercial, Federal Employee Program, Medicaid, Medicare Advantage and Dual Eligible Special Needs Plan members).
CareFirst has revised its utilization management policies and practices to reduce administrative burdens on the healthcare system effective immediately through February 15, 2022. We are partnering with our hospitals and provider networks, working together to reduce barriers and help make resources available so hospital staff and providers can care for patients when they need it most.
Hospitals that have implemented a formal process to prioritize time-sensitive admissions and cease non-urgent procedures will receive additional flexibility.
CareFirst requires notification by the facility within 72 hours of an individual admission.
CareFirst will enable greater flexibility for facilities who have implemented a formal process to prioritize time-sensitive admissions and cease non-urgent procedures. In these facilities, when we receive notification of an emergency admission, CareFirst will authorize a 30-day length of stay for members. This is intended to alleviate pressure on hospital staff to request authorization extensions. Facilities should notify their Provider Relations Representative to qualify for this flexibility.
CareFirst will not perform concurrent review during this 30-day period for those affected facilities. If authorization is required beyond the 30 days, the facility will need to contact our nurses to assist with an authorization extension.
CareFirst is extending an offer to support your teams in discharge planning. Our care managers are available to help alleviate the pressure on hospital case managers and discharge planners. We request that facility case managers and discharge planners contact our care management team to request assistance with transition of care, discharge planning and placement support for any CareFirst member.
Facility to Facility Transfers
Additionally, CareFirst is relaxing its authorization requirements for members transferring from acute-to-acute facilities, skilled nursing facilities, long-term acute care, behavioral health, acute rehabilitation and inpatient hospice facilities based on member eligibility and benefit limitations. Notification by the receiving facility to CareFirst will be required within 72 hours of an admission.
In facilities that have enabled EMR access for our care management team, we can support and expedite transfers and placements of patients that require lower levels of care.
For postponed elective procedures where authorizations have already been submitted, CareFirst will honor those initial authorizations which have been approved and maintain them in an approved status for up to six months pending member eligibility. When surgeries are rescheduled, it will be the responsibility of the provider to contact the CareFirst Utilization Management Department (866-773-2884 or via the provider portal) and provide the new date of service to ensure the claims will pay appropriately.
We expect the above protocol to be in place through February 15, 2022 but will continue to monitor hospitalization rates and capacity. CareFirst’s goal is always to remain responsive to the needs of our healthcare delivery partners while still meeting obligations to other stakeholders around affordability and accessibility of care.