CareFirst General Information Manual

Table of Contents

Manual Home

• Our Mission
• Philosophy of Care

Confidentialty Policy

• General Policy
• Routine Consent for Release of Information
• Consent for Release of Information for Other Purposes (Special)
• Member Access to Medical Records
• Treatment Setting
• Quality Improvement Measurement
• Notice of Privacy Practice

Administrative Functions

• Changes in Provider Information
• Reimbursement
• Claims Overpayment
• Timely Filing of Claims
• Coordination with Other Payers
  • Coordination of Benefits
  • Subrogation
  • No-Fault Automobile Insurance
  • Worker's Compensation

Policy Statements

Overview

• Reporting CPT® and HCPCS Codes
• Requests for Clinical Information

Basic Claim Adjudication Policy Concepts

• Unbundled Procedures
• Incidental Procedures
• Integral / Included in Procedures
• Mutually Exclusive Procedures
• Global Allowances
• Add-On Prodedures
• Unlisted Procedures
• Fragmented Billing
• Modifier Reimbursement Guidelines
• Global Surgical, Anesthesia, and Maternity Reimbursement Guidelines
• Bilateral Procedures Reimbursement Guidelines
  • Policy Guidelines for Reporting Bilateral Procedures
• Multiple Surgical and Diagnostic Procedures Reimbursement Guidelines
  • General Guidelines
  • Multiple Endoscopic Procedures Through the Same Scope
  • Multiple Endoscopic and Open Surgical Procedures
• Serial Surgery Reimbursement Guidelines
• Duplicate Procedures or Services Reimbursement Guidelines
• Multiple Provider Participation in Surgical Procedures
  • Surgical Assistant or Assistant-at Surgery
  • Team Surgery
  • Co-Surgeon
• Multiple Provider Participation in Patient Care
  • Consultations
  • Concurrent Care
  • Standby Services
• Evaluation and Management Services
  • CPT® modifier –25
  • New Patient Visit Frequency
  • Preventive Services
  • Multiple E/M Services on the Same Date
  • Counseling Services
  • Care Plan Oversight
  • E/M Services During the Global Periods
    
  • CPT® modifier –57
  • E/M Services in Conjunction with Immunizations
  • Prolonged Services
  • Intensity of Service Auditing

General and Specialty-Related Claim Adjudication Policies and Reimbursement Guidelines

• Multiple Specialties:
  • Reporting Medication Administration
  • Reimbursement for Injectables, Vaccines, and Administration
  • Collecting Copayments / Coinsurance During Global Surgical Periods
  • Special Services
  • Cerumen Removal
  • Critical Care Services
    
  • Handling and Conveyance
  • Hot and Cold Packs
  • Interpretation of Diagnostic Tests
  • Introduction of Intravenous Needles/Catheters
  • Hydration, Infusions and Injections
  • Pulse Oximetry
  • Vital Capacity Measurements
  • Supplies and Equipment
  • Miscellaneous Services
  • Venipuncture
  • Visual Acuity Testing
  • Emergency Medicine
• Surgery/Orthopedics
• Surgical Trays
• Nasal Sinus Endoscopy/Debridement
• Medicine/Oncology
• Nutrition Therapy and Counseling
• Genito-urinary
• Pediatrics/Neonatology
• Obstetrics & Gynecology
• Radiology/Imaging
• Invasive and Non-Invasive Diagnostic Tests and Procedures

Medical Policy and Technology Assessment

• Medical Policies and Operating Procedures
• Technology Assessments
  

Quality Improvement

• QI Program Design
• QI Goals and Activities
• Disease Management Programs
• Great Beginnings
• QI Committees
• NCQA
• Medical Record Documentation Standards (227KB, 7 pgs.)
• Practitioner Office Standards (205KB, 8 pgs.)