Medical Injection Preauthorization Request Form (Prior Authorization Instructions)
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Form and instructions governing prior authorization requests for medical injections (infusion or injection services) submitted to CareFirst BlueCross BlueShield Community Health Plan Maryland; affects providers requesting authorization for outpatient, inpatient, or home infusion/injection services for members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Administrative Requirements
Administrative submission criteria
Authorization requests will be processed when the following administrative information is provided:
See SECTIONs 1-7 for required fields
Provide rationale if Hospital Infusion is selected
Call 1-800-730-8543 for expedited review; requests processed after all relevant information is received
CPT codes determine the type of services requested and assume billing under the current Medicaid Fee Schedule
Approval information will be recorded by the health plan (authorization number, approval date range)
Please note: authorization does not guarantee payment. Services are not considered authorized until CareFirst issues an approval, and any authorization is subject to member eligibility and benefit plan limitations, which may affect payment.
Requested Service, Diagnosis Codes, and Timelines
| CPT/HCPCS Code(s) | Field on the form to list procedure/billing codes used to determine the type of services requested |
| Diagnosis Code(s) | Field on the form to list ICD-10 or other diagnosis codes |
Provider Submission and Billing Requirements
Prior Authorization Required
Fax completed Medical Injection Preauthorization Request Form with supporting medical documentation to: 443-753-2184.
- Form submission requirement — complete and fax the Medical Injection Preauthorization Request Form with supporting documentation to 443-753-2184.
Coding and Billing Assumption
CPT/HCPCS codes are used to determine the type of service being requested. Authorization is based on the codes submitted and assumes claims will be billed using codes that are billable under the current Medicaid Fee Schedule. Contact your Provider Relations representative with billing questions.
- Coding and billing assumption — CPT/HCPCS codes determine services requested and authorization assumes billing under current fee schedules.
Service and Coding Information Required
Provide complete service and coding details in Section 3 — include diagnosis code(s) and descriptions, CPT/HCPCS code(s), dosage/number of units, frequency/total number of treatments, scheduled date(s) of service and expected end date of service.
- Service and coding information required — include diagnosis codes/descriptions, CPT/HCPCS codes, dosage/units, frequency/total treatments, scheduled date(s) and expected end date.
Required Supporting Documentation
This request must be accompanied by a physician's order and any other pertinent clinical documentation to allow appropriate evaluation. Examples include progress notes, clinical summaries, diagnostic test results, prior treatments, and discharge information. Incomplete documentation may delay processing.
- Required supporting documentation — physician's order and pertinent clinical documentation (progress notes, summaries, diagnostics, prior treatments).
Authorization Conditional on Plan Approval
Services are not considered authorized until CareFirst issues an approval. Authorization does not guarantee payment — all approvals are subject to member eligibility and benefit plan limitations. For urgent requests, indicate "Yes" on Section 8 and call 1-800-730-8543 for expedited review.
- Authorization conditional on plan approval — services not authorized until CareFirst issues approval; subject to eligibility and benefit plan rules.
- For expedited review, call 1-800-730-8543. Expedited reviews may take up to 72 hours; standard non-urgent reviews may take up to 14 calendar days.
Policy Background
This document is an administrative prior authorization form used to request approval for medical injection or infusion services (hospital, outpatient, or home infusion). Complete and fax the Medical Injection Preauthorization Request Form with supporting medical documentation to 443-753-2184 to initiate an authorization request.
The form collects patient, provider, service, and site-of-care information needed for utilization management review. Required supporting documentation includes a physician's order and other pertinent clinical records such as progress notes, diagnostic test results, prior treatments, and discharge summaries. Provide diagnosis code(s) and descriptions, CPT/HCPCS code(s), dosage/number of units, frequency/total number of treatments, scheduled date(s) of service, and expected end date of service.
Indicate the intended site of care (Hospital Infusion, Outpatient Infusion, or Home Infusion). If Hospital Infusion is selected, include a rationale. Mark whether the request is urgent; expedited reviews may take up to 72 hours, while non-urgent reviews may take up to 14 calendar days. For expedited review or questions, call Utilization Management at 1-800-730-8543.
Key Definitions
Site of Care Requirements
Specify site of care and provide rationale for hospital infusion
Indicate the intended site of administration by selecting Hospital Infusion, Outpatient Infusion, or Home Infusion on the form; if Hospital Infusion is selected, provide a rationale.
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