Prior Authorization

Prior authorizations (also called pre-certifications) are reviews and assessments of medical services. They are designed to help ensure that our members receive the right care, at the right time, in the right location.

Our providers submit authorizations as needed based on medical policies and clinical guidelines.

More information about prior authorization requirements can be found here.

What You’ll Find on This Page

• What is a prior authorization?
• How do I submit an authorization?
• What services require a prior authorization?
• Why prior authorization requests are denied
• Appeals and grievances mandated by the DC Prior Authorization Reform Amendment Act of 2023

At CareFirst BlueCross BlueShield (CareFirst), we are committed to ensuring our members receive timely, affordable and appropriate care. Prior authorization is a standard part of managing healthcare services, helping to ensure that treatments are medically necessary and aligned with evidence-based guidelines.

While prior authorization is sometimes viewed as a barrier, the reality is that the vast majority of CareFirst requests are approved. In 2024 and 2025, an average of 92% of prior authorization requests for CareFirst members were approved on the first review.*

When denials do occur, they are often due to missing documentation or incomplete information from the provider. For DC risk only: Once the necessary details are submitted through an appeal, approximately 60% of these requests are approved. This process supports high-quality care while protecting members from unnecessary or potentially harmful treatments.

What is a prior authorization?

A prior authorization, or pre-certification, is a review and assessment of planned services that helps determine medical necessity and appropriateness. This process protects members from unnecessary or potentially harmful treatments and promotes efficient use of healthcare resources. Prior authorizations are not a guarantee of payment or benefits.

How do I submit an authorization?

When a member seeks services from an in-network provider within the CareFirst service area, the provider is responsible for obtaining prior authorization and/or reauthorization. For out-of-network providers, while many do submit prior authorization requests, it is ultimately the member’s responsibility to ensure that authorization requirements are met.

Most prior authorization requests are submitted through the CareFirst Provider Portal. This portal guides providers through a step-by-step process to ensure all required information is included, reducing delays and denials due to missing documentation. Training is available in our Provider Learning and Engagement Center.

What services require a prior authorization?

To determine which services or prescriptions require prior authorization, visit:

• In-Network Prior Authorizations
• Out-of-Network Prior Authorizations
• Pharmacy Prior Authorizations

Providers can also use the Prior Authorization Lookup Tool in the CareFirst Provider Portal. Members can view additional clinical guidelines on the CareFirst Member Portal.

Why prior authorization requests are denied

Common reasons for denial include:

• Missing or incomplete clinical documentation
• Failure to meet medical necessity criteria
• Submission of incomplete request forms
• Requested service does not have a covered benefit

Providers submitting prior authorization requests through the CareFirst Provider Portal significantly reduces preventable errors by guiding providers through a standardized, step-by-step process that ensures all required information is included upfront.

Appeals and Grievances

Members, their authorized representative, or provider acting on behalf of the Member, have the right to file an appeal or grievance regarding denials to CareFirst. On a case-by-case basis, it may be discussed with the member’s physician or a board-certified specialist. Additional information on appeals can be found on our Prior authorization and appeals webpage.

The majority of clinical grievances are approved after additional information is submitted—often information that was missing from the original request. Submitting complete prior authorization requests through the Provider Portal can reduce the likelihood of denials and the need for appeals and grievances.

Prior authorization and appeals statistics

*This percentage represents pre-service review approvals directly decisioned by CareFirst for fully insured plans.

This page is provided in accordance with a District of Columbia law requiring health plans to publish prior authorization and appeals statistics.

Please see below Prior Authorization requirements for individual jurisdictions.

District of Columbia Continuation of Care Form (PDF)

Prior Authorization and Appeals Information and Documentation (PDF)