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Administrative Functions
Changes in Provider Information
CareFirst and CareFirst BlueChoice health care providers who need to change their provider information must complete the Change in Provider Information Form.
Print the form and complete the applicable information, including the information regarding accepting new patients (open/close panel). Be sure to include your office letterhead when returning the completed form.
The mailing address is:
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.
Provider Information and Credentialing
Mailstop CG-41
10455 Mill Run Circle
Owings Mills, Md. 21117-0825
You may also fax the completed form to: 410-872-4107.
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Reimbursement
Participating providers agree to accept a plan allowance (also called allowed benefit or allowed amount) as payment in full for their services. Participating providers may not bill the member for amounts that exceed the allowed amount for covered services. Members are liable for non-covered services, deductibles, copayments and coinsurance.
A physician fee schedule is a list of plan allowances that are reviewed regularly. When adjustments to the fee schedule are made, providers receive a list of the top 20 billing codes according to their specialty.
Reimbursement for LLPs
CareFirst reimburses limited licensed providers (LLPs) at a percentage of the physician fee schedule. This reimbursement policy applies to both Group Hospitalization and Medical Services, Inc. (GHMSI) and CareFirst of Maryland, Inc. (CFMI) provider contracts.
Specialties affected and related percentage of the physician fee schedule:
| Clinical psychologist |
90% |
| Nurse midwives |
90% |
| Social workers |
75% |
| Psychiatric nurses |
75% |
| Nurse practitioners |
75% |
| Dieticians/Nutritionists |
75% |
| Licensed counselors |
75% |
CareFirst reimburses Surgical Assistants at 20% of the physician fee schedule. This reimbursement policy applies to both GHMSI and CFMI provider contracts.
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Claims Overpayment
If a claims overpayment is discovered and you wish to return the payment to CareFirst, please mail it to the following address:
CareFirst BlueCross BlueShield
PO Box 791021
Baltimore, MD 21279
Please make the check payable to CareFirst and include the membership number, patient's name, claim number, and the reason for the refund
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Timely Filing of Claims
To be considered for payment, claims must be submitted within 365 days from the date of service.
To ensure quick and accurate claims processing, please report services for only one practitioner per claim. If more than one provider in your practice renders services for a given member, separate claims must be submitted for each practitioner.
Reconsideration
Claims submitted beyond the timely filing limits generally are rejected as not meeting these guidelines. If your claim is rejected, but you have proof that the claim was submitted to CareFirst within the guidelines, you may request processing reconsideration.
Timely filing reconsideration requests must be received within six months of the provider receiving the original rejection notification on the provider voucher or notice of payment. Requests received after six months will not be accepted and the charges may not be billed to the member.
Documentation is necessary to prove the claim was submitted within the timely filing guidelines.
For electronic claims: A confirmation from the vendor or clearinghouse that CareFirst successfully accepted the claim. Error records are not acceptable documentation.
For paper claims: A screen print from the provider's software indicating the original bill creation date along with a duplicate of the clean claim or a duplicate of the originally submitted clean claim with the signature date in field twelve (12), indicating the original bill creation date.
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Coordination with Other Payers
Coordination of Benefits
Coordination of benefits (COB) is a cost-containment provision included in most group and member contracts which is designed to avoid duplicate payment for covered services. COB is applied whenever a member covered under a CareFirst or CareFirst BlueChoice contract is also eligible for health insurance benefits through another insurance company or Medicare.
If CareFirst or CareFirst BlueChoice is the primary carrier, benefits are provided as stipulated in the member's contract.
The member may, however, be billed for any deductible, coinsurance, non-covered services or services for which benefits have been exhausted. These charges may then be submitted to the secondary carrier for consideration.
Group contracts may stipulate different methods of benefits coordination, but generally, CareFirst and CareFirst BlueChoice's standard method of providing secondary benefits for covered services is the lesser of—
- The balance remaining up to the provider's full charge; or
- The amount CareFirst or CareFirst BlueChoice would have paid as primary, minus the other carrier's payment (i.e., the combined primary and secondary payments will not exceed CareFirst or CareFirst BlueChoice allowance for the service).
Note: When coordinating benefits with Medicare, the amount paid by CareFirst or CareFirst BlueChoice-when added to the amount paid by Medicare - will not exceed the Medicare allowable amount. Claims for secondary benefits must be accompanied by the explanation of benefits (EOB) from the primary carrier.
Subrogation
Subrogation refers to the right of CareFirst or CareFirst BlueChoice to recover payments made on behalf of a participant whose illness, condition, or injury was caused by the negligence or wrong-doing of another party. Such action will not affect the submission and processing of claims, and all provisions of the participating provider agreement apply.
No-Fault Automobile Insurance
The no-fault automobile insurance laws may require the automobile insurer to provide benefits for accident related expenses without determination of fault. A copy of the record of payment from the automobile insurer must be attached to the claim form submitted to CareFirst or CareFirst BlueChoice.
Workers' Compensation
Health benefits programs administered by CareFirst and CareFirst BlueChoice exclude benefits for services or supplies to the extent that the participant obtained or could have obtained benefits under a Workers' Compensation Act, the Longshoreman's Act, or a similar law. Affected claims should only be filed if workers' compensation benefits have been denied or exhausted. In the event that CareFirst or CareFirst BlueChoice benefits are inadvertently or mistakenly paid despite this exclusion, CareFirst or CareFirst BlueChoice will exercise its right to recover its payments.
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