Effective April 1, 2023
The following provides information on standard services that require authorization and notification by any physician/provider/facility (both participating and non-participating) on a variety of services including routine, elective, and urgent services, inpatient or outpatient, to Community First Health Plans, Inc. (Community First).
NOTE: This summary is not all-inclusive of Community First Prior Authorization requirements. Refer to this link for Referral & Prior Authorization information.
- Timely notification (within 24 hours) of an inpatient admission AND discharge is required for all facilities. Includes pre-planned admissions, urgent admissions, and within 24 hours of post-stabilization care.
- Prior authorization is required for inpatient facility-to-facility transfers, NICU/Special Care Nursery admissions, intraoperative monitoring, and elective inpatient admissions.
- Admission to a behavioral health, substance abuse residential facility, partial hospitalization, day programs, and intensive outpatient programs requires prior authorization.
- Inpatient admission to a facility that is not contracted with Community First requires inpatient notification within 24 hours and subject to concurrent review for medical necessity.
Note: Physicians and providers who are not participating in the Community First network must confirm the inpatient authorization status with the hospital billing department.
Outpatient Non-Participating Physician and Provider Services
Prior authorization is required for all referrals to non-participating physicians and providers and must be requested by a participating physician.