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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

®Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc. PAUserGuide (7/15)

Prior Authorization User Guide July 2015 SCOPE This manual reviews the navigation and functionality of the Medical Prior Authorization system specifically as it is utilized by CareFirst BlueCross BlueShield and/or CareFirst BlueChoice, Inc. (CareFirst) provider users.

Table of Contents 1. LOGGING IN…………………...…….……………….…………………………..……………………….….2

2. CREATING AN AUTHORIZATION REQUEST….…………………………………………………..…10

STEP 2 – PATIENT DETAIL…………………………………………………………..……….……10 STEP 3 – ENTER AUTHORIZATION DETAIL…………………………………………..……....11

STEP 4 – ENTER AUTHORIZATION LINE………………..……………..……………………...13

3. HOW TO ENTER NOTES…………………………………………………………………………………...17

4. HOW TO ATTACH DOCUMENTS………………………………………………………………………...19

5. FIND AN AUTHORIZATION………………………………………………………………………………20

6. FILTERS…………………………….………………………………………………………………………….22

7. PROVIDER NOTIFICATIONS………………………………………………..…………………………..25

8. MODIFY AN APPROVED AUTHORIZATION………………………………………………………….27

9. PROVIDER ACTION…………………………………………………………………………………………31

Prior Authorization User Guide – July 2015

Confidential and Proprietary Page 2 of 34

Not To Be Reproduced Or Disclosed to Others Without Prior Written Approval ELECTRONIC DATA = OFFICIAL VERSION – PAPER COPY – INFORMATIONAL ONLY

1. LOGGING IN

Navigate to the CareFirst website: https://provider.carefirst.com/providers/home.page and click

on the orange tab in the upper right hand corner.




Enter user information and then click on Login.

Log in to the CareFirst Provider Portal by entering your User ID and password and click Login




Click on the Pre-Auth / Notifications Tab on the top left of the screen.

Click the Pre-authorizations tab




Click on Add New and Drug Pre-Authorization from the drop down lists.




Enter the member information. Please note: the Member ID is required as indicated by the orange

asterisk. Then click on Search.




The system shows the appropriate member and automatically selects radio button (as shown

above)

And then click on Submit.




If the member has Medical Coverage only, the system requires you to select the drug to determine

if it is a drug which requires pre-authorization. Follow the prompts on the screen.




If there are more than one NPI numbers under your tax id you will see this screen and you will

select the correct provider from the drop down list. Then click on Submit.




2. CREATING A PREAUTHORIZATION REQUEST

All authorizations that have been submitted will be available through the Find Authorization option. See page 18 for instructions.

The member information will be automatically populated in the Step 2 – Enter Patient Detail. Click Next to continue. The grayed areas in the screen shot above, indicate fields which are populated.




Step 3: Enter Auth Details

Enter the first 3 numbers of the Requesting Provider’s NPI, or Enter the first 3 letters in the Requesting Provider’s name The system will provide a listing with those numbers or letters – as show above in

the dropdown list. Click the correct Requesting Provider, and the system will populate the Name and

Address of that particular provider. Repeat preceding steps to enter the Referring Provider information. Please note: the red asterisks are required fields and need to be filled out prior to

moving to the next step.




Enter the Authorization Priority, as indicated by the red asterisk. Then click the Next

button.

Normal priority has a 2 day turnaround time

Urgent priority has a 24 hour turnaround time

Once the authorization approaches the end of the turnaround time (24 hours) the authorization line turns yellow.

Once the authorization has passed the turnaround time, the authorization line turns red.




Step 4: Enter Authorization Lines

Enter the required fields as indicated by the red asterisks.

Place of Service – click on the arrow to change the place of service

Dates of Service – automatically set for the day auth is entered and is set for a year.

The “to” date can be changed to a different date.

NDC Code – enter the first 3 letters or 3 numbers of the NDC code

The system will then populate a list with those items.

Scroll down to find the NDC or Drug Name

Click on the appropriate NDC or Drug Name

The system will populate the NDC Code, Drug Name, Strength/Measure, Dosage Form and Package Size

Click the Next Button when completed with the all the required fields.




Review information entered under the Authorization Detail Screen. If no changes are needed, select Submit, to move on to the clinical questions

*If you would like to print your request, you may do so by expanding all collapsed fields on the screen and printing prior to clicking the Submit button.




Answer clinical protocols as they are presented in the pop up screen, and click Next to move on

to the next question.

Once clinical protocols have been completed, click Done.

Based on the clinical information, the authorization may be Approved or sent to Clinical Review.

The protocol questions screen will then close and the authorization request will be:

Approved, or

Sent to Clinical Review for assessment based on clinical criteria.




The authorization has been approved. Please note the status.

Also, the authorization has been assigned an authorization number.




The authorization detail will also display the Protocol Questions and corresponding answers.




3. HOW TO ADD NOTES

After creating an authorization, adding notes is an option.

Click Add Note

Enter the desired note in the notes window and click Save.




4. HOW TO ATTACH DOCUMENTS

Additional documentation can be added to any authorization at any time.

Select Add Document

If prompted to add a document during the clinical question process, you can save and close your clinical questions and add the document or you can add after the questions have been completed.

Browse through your directories to locate the desired file

Select Document

Rename the document

Click Upload to attach




5. FIND AN AUTHORIZATION

From the Homepage select the Authorization tab on the top navigation menu then

select Find Authorization.

Enter Search Criteria

Click Search




Select the Authorization to be reviewed from search results, by clicking on the Auth # in blue font.




6. FILTERS

When selecting authorizations to work, from a specific shared queue in your workbox on your homepage, you have the ability to apply filters to view only the authorizations you want to see.

Expand the queue, by clicking on the + sign, to view and apply your filter to by clicking on the queue name.

For this example, click on the Shared Work Items Queue




On the right-hand side of the workbox, click Show Filters.




Enter the wanted data in the corresponding filter field(s).

In this example, Actiq is the drug being searched.

Click Filter to apply your request.

The results will be presented in the Workbox Items on the Home Page.




7. Provider Notifications

Once the authorization has gone through Clinical Review, there will be a provider notification as to whether the authorization has been approved or denied.

From the Home Page, click on the Provider Notification queue, to get a list of Provider

Notifications.

Click on the Provider Notification (in blue text; auth #12012).




By clicking on a specific authorization, the authorization details are shown. For this authorization, it was auto Approved.

There is a general note to reference as well.

Click on the Accept Notification button. By clicking on the button, the authorization is taken out of the Shared Work Queue.

If the wrong authorization was clicked, click on the Return Button. The system will close the authorization and keep it in the Shared Work Queue.

Other options available are Copy and Save.

Copy allows the provider to quickly start an auth and make minor changes to the requested authorization dates or to the drug requested.




Above is an example of a Denied Authorization.

Click on the Accept Notification button. By clicking on the button, the authorization is taken out of the Shared Work Queue.

If the wrong authorization was clicked, click on the Return Button. The system will close the authorization and keep it in the Shared Work Queue. It will not be assigned to anyone.

Other options available are Copy and Save.

Copy allows the provider to quickly start an auth and make minor changes to the requested authorization dates or to the drug requested.

Save allows the provider the option of saving work prior to completing task. The auth will be saved to My Work Queue.




8. Modify Approved Authorizations

If there is an error with the Approved authorization, click on the Modify button (to make

changes and have it reassessed by Clinical Review).




Click on the Modify button and it will display the Modify Authorization pop-up box.

Click in the Modify Reason box, and type a reason as to why the authorization needs to be modified.

When completed, click on the Modify Button at the bottom of the pop-up box.




When all the changes have been made, click on the Release button.

The authorization will be released to Clinical Review for Approval or Denial.

Once Clinical Review has been made, there will be a Provider Notification sent to the Provider with the results of the review.

Provider Notifications will be visible on the Home Page.




9. PROVIDER ACTION There are situations when Clinical Review has reviewed an authorization request but needs additional information from the Provider.

On the Homepage, in the Workbox Items, there will be a Provider Action – Info Request.

Click on the Provider Action – Info Request, in blue font, to open the authorization.




The Notes & Documents section will be important to review in order to understand what is

needed for the clinical team to determine final status.

In this case, the EOB and the written prescription need to be provided so the review can be finished and the authorization finalized with an approval or denial.

Click on the Respond button, to attach documents.




Browse through directories to locate the desired file

Name the document – or Title the document

Select Document

Rename the document – in this example the document was renamed to EOB

Click Upload to attach




Once the documents have been uploaded, the authorization is automatically sent to Clinical Review.

Please note: if there was an error with the document, the document can be deleted by clicking on the red x in the Command column.

The workflow has completed.

Clinical review will send a provider notification once decision is made.