CareFirst Implements New Prior Authorization Requirements for Advanced Imaging Services
CareFirst BlueCross BlueShield recently announced prior authorization changes for advanced imaging services in cardiology and radiology services, which will impact members enrolled with fully insured commercial coverage. This is an update stemming from the ongoing work between CareFirst and EviCore on enhancing the management of these services.
Effective August 2, 2024, the following identified advanced imaging procedures in cardiology and radiology will require prior authorization for the CareFirst commercial fully insured members on the Facets system. Providers have been able to submit prior authorization requests since July 15, 2024.
A provider must research three pieces of information to verify if prior authorization is required:
- Commercial Membership: The membership shall not be included in any of the following government programs, that are Federal Employee Program, FEP, Medicare Advantage, or CareFirst CHPMD. If participating in one of these, then they are not a commercial member, and prior authorization is not required for that member.
- Fully Insured Status: Providers must confirm the member is fully insured, or "RISK," with CareFirst. If the member is self-insured, or "NON-RISK," prior authorization is not required.
- Facets System Association: The member must be associated to the Facets source system. This can be confirmed on the CareFirst Direct Eligibility Summary screen.
Members meeting all three criteria would be required to have prior authorization for the imaging services identified. Providers can refer to a comprehensive list of codes requiring prior authorization on EviCore's Health Resource Page for CareFirst, under the 'Solutions Resources' tab.
CareFirst has several resources available to help providers navigate these changes. These include guides about the prior authorization request process via the EviCore portal and how to determine if an authorization is on file. Recordings of the live webinars held in July are also available for those who are unable to join.
This is an important update in that it makes all advanced imaging services management is preceded by necessary approvals, probably reducing unneeded procedures and enhancing coordination in care.
