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The list is not inclusive:. Designed and Powered by Inroads. Powered by QuikWeb Developer. Thank you for your help. Report incorrect info for www. Help us stay up to date. Use this form to let us know about corrections and we'll follow up. Email A Friend Print. Medical Pre-Authorization. Pharmacy Drug Formulary Resources. Additional Provider Resources. Provider Connections. Provider Resources. Provider Training. Live webinars hosted using Microsoft Teams will begin on June 14, and will be offered 3 times a week.

Click here to register for an upcoming webinar. You only need to attend one session. Cosmetic Services This is not an exclusive list All cosmetic services. Contact Avesis to determine if the procedure requires prior authorization. Below knee, molded socket, shin, sach foot. Orthotic and Prosthetic Procedures, Devices Below knee, molded socket, shin, sach foot, endoskeletal system.

Orthotic and Prosthetic Procedures, Devices Addition to lower extremity, below knee, flexible inner socket, external frame. Orthotic and Prosthetic Procedures, Devices.

Addition to lower extremity, below knee suction socket. Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation Addition, endoskeletal system, below knee, flexible protective outer surface covering system. All cpt codes ending in To ensure you are receiving the most appropriate medication for your condition s , additional information may be required from your doctor before filling certain prescriptions.

In those instances, CareFirst will work with you and your doctor to manage the process. To see whether your drug is excluded or requires prior authorization, step therapy or quantity limits, visit the Drug Search page and select your plan year to find your specific formulary.

If the drug does not meet the needs of your particular condition or is excluded from the formulary, your doctor can request an exception with a Prior Authorization Form. To ensure our members have access to safe and effective care, CareFirst reviews new developments in medical technology and new applications of existing technology for inclusion as a covered benefit.

We evaluate new and existing technologies for medical and behavioral health procedures, medications and devices through a formal review process. We also consider input from medical professionals, government agencies and published articles about scientific studies.

If you have concerns regarding a decision that adversely affect coverage, such as a denial, a reduction of benefits, or a denial of authorization for services, you may call the Member Services telephone number on the back of your member ID card.

A representative can assist you with resolving the issue or initiating the appeal process. If needed, language interpretation is available. If you would like to review the procedure for filing an appeal, visit carefirst. For a printed copy, call Member Services at the telephone number on the back of your member ID card.

In addition, many members have a right to an independent external review of any final appeal or grievance decision.

Refer to your Evidence of Coverage for more specific information regarding initiating an external review, a final appeal determination or a complaint.

If you need language assistance or have questions, call the Member Services telephone number on the back of your member ID card. Get a Quote. Skip Navigation. Login Register. Have questions about health insurance? Explore our Insurance Basics pages.

Need Insurance? Log In or Register. Insurance Basics. We know healthcare can be complicated. To learn more, choose a topic from the list below. Expand All Collapse All Covered benefits. All of our plans include core health benefits, including: Office visits Maternity and newborn care Prescription drugs Laboratory tests and X-rays Preventive and wellness care Dental and vision for children under age 19 Emergency services Hospitalization Behavioral health and substance use disorder Physical, speech and occupational therapy.

Common non-covered benefits. Finding a primary care provider. Finding a specialist, behavioral health or hospital resource.

After office hours or emergency care. Out-of-area care and benefit coverage. How to submit a claim. You can submit your claim one of two ways: Mail your claim form To print and mail your claim form, log in to My Account, select the My Documents tab, choose Forms. Choose the form for your type of claim and fill in the required information. Then, mail the form using the directions included. If you do not have internet access, you may request a paper claim form by calling Member Services at the telephone number on the back of your member ID card.

Submit your claim form online CareFirst also offers online claims submission for medical, dental and behavioral health claims. From your computer or mobile device, log in to My Account and select Claims. Enter the requested information, upload the required documents and submit. Understanding the review process. The medical review process includes, but is not limited to: Preservice review The preservice review serves as a check to assure that members receive the right service in the right setting at the right time.

Requests for review include high-cost, complex inpatient, experimental, cosmetic, and outpatient services. The preservice review also helps ensure services are provided by in-network providers. Your doctor must initiate your authorization request. All admissions are reviewed and categorized by severity level.

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How to Conveniently Verify Your Client's Eligibility, Service Authorizations and Reassessments?

Contact () for authorization regarding treatment. Any drugs, services, treatment, or supplies that the CareFirst medical staff determines, with appropriate consultation, to be . Process for Obtaining Pre-Service Review Information To view the out-of-area Blue Plan's medical policy or general pre-certification/pre-authorization information, please: Select the type . PREAUTHORIZATION REQUESTFORM. FAX COMPLETED FORM WITH SUPPORTING MEDICAL DOCUMENTATION TO: or SECTION 1 - MEMBER .