Authorization Guidelines
Summary of services that require prior authorization
Download a copy of the 2025 Authorization Guidelines.
Payment Policy: Hospital Inpatient and Observation Admissions Authorization Requirements
Obtaining prior authorization is the responsibility of the PCP or treating provider. Members who need prior authorization should work with their provider to submit the required clinical data.
Submit the request in one of the following ways:
- via fax to 443-552-7407 / 443-552-7408.
- via telephone at 800-730-8543 / 410-779-9359.
Click here to download a copy of our preauthorization request forms.
Click here to download a copy of our medical preferred drug list.
Important Information
- The Authorization Guidelines document is not all inclusive.
- All inpatient services require authorizations.
- All outpatient services in the below categories and/or outpatient services and procedures by a non-par facility or non-par provider require an authorization.
- Authorization is not a guarantee of payment.
- All authorizations are subject to eligibility requirements and benefit plan limitations.
- Authorizations are issued for medical services and assumes that providers submit claims with codes billable under the current Medicaid Fee Schedule contact Provider Relations with questions.
- Verification of eligibility and/or benefit information is not a guarantee of payment.
- Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of coverage applicable on the date services were rendered.
Medical Drug Prior Authorization List
CareFirst Community Health Plan Maryland (CareFirst CHPMD) will require prior authorization (PA) on certain medical drugs. Prescribers must complete the entirety of the medical injection preauthorization request form with supporting medical documentation and send to CareFirst CHPMD to render medical necessity coverage determination. Failure to do so will result in non-payment. You will not be reimbursed without an approved prior authorization.