CareFirst BlueChoice Manual

Welcome | Table of Contents | Phone Numbers | Membership | Arranging for Care | Benefits | Administrative Functions

Benefits, Exclusions and Limitations

Covered Services and Benefit Guidelines

You should always obtain verification of benefits. Information regarding a member's specific benefit plan can be verified by contacting FirstLine or by visiting CareFirst Direct.

This section includes general policies and procedures related to CareFirst BlueChoice HMO, CareFirst BlueChoice HMO Open Access, CareFirst BlueChoice Opt-Out Open Access, CareFirst BlueChoice Opt-Out Plus and CareFirst BlueChoice Opt-Out Plus Open Access (in-network benefits). Unless otherwise stated, all office services not rendered by a PCP require a written referral, except for OB-GYN services and services rendered for members with the Open Access feature. Unless otherwise indicated, a written referral is valid for a maximum of 120 days and limited to three visits except for long-standing referral situations, and in-network services rendered to CareFirst BlueChoice members with the Open Access feature included in their coverage.

Decisions to issue additional referrals rest solely with the PCP. Please refer to the referral process in the Arranging for Care section of this manual for exceptions related to referrals. The hospital must obtain prior authorization for inpatient hospital admissions, except in emergencies.

Additional information about covered services and benefits guidelines are available via the Medical Policy Reference Manual and the Claim Adjudication and Associated Reimbursement Policy of the CareFirst General Information Provider Manual. If you have additional questions, contact Provider Services.

It is the expectation of CareFirst and CareFirst BlueChoice that all providers who perform laboratory or imaging tests, at any site, will obtain and/or maintain the appropriate federal, state, and local licenses and certifications; training; quality controls; and safety standards pertinent to the tests performed.

top

Abortion

An authorization from Care Management is required to perform an abortion in a hospital setting. Authorization is not required if performed in a provider's office.

Note: Benefits for abortions are not available under all programs.

top

Allergy

Allergy services require a written referral from the member's PCP.*  A PCP may issue a long-standing referral for allergy services. Please refer to the Extended Referral process in the Arranging for Care section. Allergy consultation, injections, testing and serum are generally covered.

PCPs may administer allergy injections and must maintain appropriate emergency drugs and equipment on site.

Contact FirstLine or visit CareFirst Direct to determine the member's level of coverage.

*Written referrals are not required for members with the Open Access feature.

top

Ambulance

Ambulance services involve the use of specially designed and equipped vehicles to transport ill or injured members. Benefits for ambulance services are provided for medically necessary ambulance transport. Services must be authorized through Care Management, except for emergency situations.

Emergency ambulance services are considered medically necessary when the member's condition is such that any other form of transportation would be medically contraindicated and would endanger the member's health. For more information, please refer to the administrative services section of the Medical Policy Reference Manual. Look in the Table of Contents for Medical Policy 10.01.05, Ambulance Services.

top

Anesthesia

CareFirst BlueChoice provides benefits for anesthesia charges related to covered surgical procedures and for pain management. Authorization for anesthesia during surgery is included in the authorization for the surgery. For pain management services rendered in a physician's office, a referral from the PCP is required.
For more information about reporting anesthesia services, please refer to anesthesia policies in Section 9 of the Medical Policy Reference Manual.

top

Cardiology

Radiological services covered under the member's medical benefit and performed in the cardiologist's office setting are limited to the following procedures. All other procedures must be performed by a CareFirst BlueChoice contracted radiology facility. For descriptions of the following codes, please refer to your current CPT® or HCPCS code book.

Be sure to verify member eligibility and coverage prior to rendering services, as benefit limitations and medical policy requirements still apply.

top

Chemotherapy

Chemotherapy services rendered in a specialist's office require a written referral from the PCP.* The PCP may issue a long-standing referral. Refer to the Extended Referral process in the Arranging for Care section in this manual. Services rendered in a hospital setting must be authorized by Care Management.

*Written referrals are not required for members with the Open Access feature.

top

Chiropractic Services

Chiropractic services require a written referral from the PCP, except when rendered to CareFirst BlueChoice members with the Open Access feature included in their coverage. Benefits are limited to spinal manipulation for acute musculoskeletal conditions of the spine for individuals over the age of 12 years. Refer to the Spinal Manipulation and Related Services, policy 8.01.03, in the Medical Policy Reference Manual. Copayments for specialty office visits apply and there are limitations on number of visits, which vary by contract.

To verify a member's level of coverage, call FirstLine or visit CareFirst Direct.

top

Dental Care

Some members are eligible to receive dental services through the CareFirst BlueChoice Dental Program, administered by The Dental Network (TDN). This discounted fee-for-service plan allows members to select a primary care dentist from TDN's directory and receive a discounted rate for specific dental services. For inquiries, contact TDN*.

Restorative dental services for accidental injuries that are generally covered under the member's medical benefit are limited to repairing or replacing sound, natural teeth that have been damaged or lost due to an injury. Limitations apply. Please call FirstLine or visit CareFirst Direct to verify a member's level of coverage.

*The Dental Network is an independent licensee of the BlueCross and BlueShield Association.

top

Durable Medical Equipment, Prosthetics and Orthotics

Care Management must authorize services related to prosthetics, orthotics, and certain other DME items except when using Network Health Services (NHS)/NeighborCare. Authorization is also required from Care Management when the contracted provider supplies all DME equipment and supplies for diagnoses other than asthma and diabetes. For members with asthma and/or diabetes, the attending physician is responsible only for a written prescription to the participating DME provider.

Note: To contact NHS, call 800-707-8520. To verify a member's level of coverage, contact FirstLine or visit CareFirst Direct.

Supplies That Can Be Provided in a Physician's Office

CareFirst BlueChoice primary care physicians, physical therapists, podiatrists, orthopedists and chiropractors can provide the following medical supplies in their office when these supplies/devices are rendered in conjunction with an office visit. No separate authorization is needed; however, member benefits must be verified prior to providing supplies, as medical benefit limitations, policies and procedures still apply.

Below is a list of HCPCS codes, also known as “immediate need supplies” that can be dispensed in an office setting.

If a provider chooses not to supply an “immediate need” item to a member, then the provider must refer a member to a contracted DME supplier. Contracted DME providers must distribute all other supplies not considered an “immediate need.” Find a list of current DME suppliers.

Note: If required under the member’s benefits, specialists providing immediate need supplies must receive a written referral from the member.