CommercialPrior AuthHigh impact
Effective March 3, 2025, New Level of Care (LOC) Review Process for Inpatient NICU Authorizations (MD Only Facilities)
CareFirst BlueCross BlueShield·MD · Pediatrics, Critical Care·Provider News
Effective date
Mar 3, 2025
We identified it
Jun 20, 2026
Summary
Beginning March 3, 2025, CareFirst will implement level of care reviews for inpatient NICU prior authorization requests in Maryland facilities to ensure appropriate duration and care levels using MCG Clinical criteria. If the documented level of care doesn't meet established criteria, bed days or authorization requests will be denied, with options for resubmission with updated care levels or peer-to-peer review.
Action Required
By March 3, 2025: NICU providers and billing teams must ensure all inpatient NICU prior authorization requests include appropriate revenue codes indicating correct level of care (Routine, Continuing, Intermediate, or Intensive Care per MCG LOC-010 criteria). Update clinical documentation processes to support concurrent level of care reviews. Train staff on MCG Clinical Criteria Tool and establish protocols for resubmitting requests with updated care levels or initiating peer-to-peer reviews (410-528-7041) when denials occur. Failure to provide adequate documentation will result in bed day or authorization denials.