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Home Care Authorization Form - CareFirst

1 Home Care Authorization FormCUT6137-1E (6/18)IMPORTANT1. Claims submitted for these benefits are subject to lifetime maximums and any applicable deductions, coinsurances or provisions, as specified in the member s contract. Benefits issued for requested services will be subtracted from the member s lifetime benefit maximum. Benefit approval is subject to the following conditions: a) member identification number is effective at the time services are rendered, b) requested benefits are available under the member s contract, c) lifetime benefits not When submitting claims for habilitative services, the modifier 96 must be included.

CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc.

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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 of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and

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