Community First Health Plans is aware that a previous version of this notice published on February 13, 2023 may have caused some confusion amongst our network of Providers. We have updated the notice for clarity. Please contact Provider Relations at 210-358-6294 or email ProviderRelations@cfhp.com if you have any questions or need support.
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.
Hospital/Inpatient Admissions
- 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.