CommercialPrior AuthHigh impact
Important Outpatient Therapy and Home Health Prior Authorization Entry Guidelines
CareFirst BlueCross BlueShield·Physical Therapy, Occupational Therapy, PM&R (Physical Medicine & Rehab)·Prior Authorization
Effective date
Oct 27, 2025
We identified it
Jun 20, 2026
Summary
CareFirst is implementing new requirements for outpatient therapy and home health prior authorization requests, requiring all relevant modality codes and visit counts to be submitted together through their electronic portal. Claims must match the exact codes included in the prior authorization request.
Action Required
By October 27, 2025: Billing team must update CareFirst prior authorization workflow to include ALL modality codes for each therapy request (not just primary codes) and specify visit counts for each code. Staff must transition to electronic submission through CareFirst Provider Portal instead of faxing requests. Update billing system to ensure claims match exactly with codes submitted on prior authorization requests, as mismatched codes will likely result in denials.