Institutional Manual

Membership and Product Information

ID Cards

Member's Rights and Responsibilities

• Members have a right to be treated with respect and recognition of their dignity and right to privacy.
• Members have a right to receive information about the Health Plan, its services, its practitioners and providers, and members' rights and responsibilities.
• Members have a right to participate with practitioners in decision making regarding their health care.
• Members have a right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
• Members have a right to make recommendations regarding the organization's members' rights and responsibilities policies.
• Members have a right to voice complaints or appeals about the Health Plan or the care provided.
• Members have a responsibility to provide, to the extent possible, information that the Health Plan and its practitioners and providers need in order to care for them.
• Members have a responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
• Members have a responsibility to follow the plans and instructions for care that they have agreed on with their practitioners.
• Members have a responsibility to pay member copayments or coinsurance at the time of service.
• Members have a responsibility to be on time for appointments and to notify practitioners/providers when an appointment must be canceled.

BlueCard®

Out-of-Area Program - BlueCard
The BlueCard Program allows members of Blues Plans to seek care from health care providers participating in any Blues Plan across the country and abroad with a single electronic network for professional and institutional claims processing and reimbursement. The program allows providers participating in any Blues Plan to submit claims for out-of-area members to their local Blues Plan.

BlueCard Member Identification
To identify BlueCard members, look on the member's identification card for an empty suitcase, or for PPO members, a "PPO" in a suitcase. BlueCard members also have alpha prefixes on their membership number so that the processing Plan can identify the Plan to which the member belongs.

If you see a member's ID card without an alpha prefix, call the member's home Plan. The phone number will be on the back of the ID card.

How the BlueCard Program Works
If you participate with CareFirst only and the member has a contract with another Blues Plan, submit claims to CareFirst.

CareFirst will be your sole contact for claims submission, claims payments, adjustments, services and inquiries. Call 800-676-BLUE or log on to CareFirst Direct for eligibility information on out-of-area members (Click here for more information on CareFirst Direct).

Contiguous Areas
In some cases, your office or facility may be located in an area where two Blue Cross and Blue Shield Plans share a county. Outlined below are processes for filing claims under these circumstances:

• If you provide care to a member from a county bordering CareFirst's service area and you do not contract with that member's Blues Plan, submit the claim to CareFirst.
• If you provide care to a member of a Blues' Plan in a county bordering CareFirst's service area and you contract with both CareFirst and the Plan in the bordering area, submit the claim to the Plan in the bordering area.

Exclusions
The Program excludes Federal Employee Health Benefit Plan (FEHBP) member claims and routine vision exam, vision correction material, dental and prescription drug coverage.

Utilization Review
Out-of-area members are responsible for obtaining preauthorization for their services from their Blue Cross and Blue Shield Plan. Providers may choose to contact the member's Plan on behalf of the member. If you choose to do so, refer to the phone number on the back of the member's ID card.

BlueCard Program Claims Submission
Submit BlueCard claims and correspondence to:

MD BlueCard Claims
Mail Administrator
P.O. Box 14115
Lexington, KY 40512-4115

NCA BlueCard Claims
Mail Administrator
P.O. Box 14116
Lexington, KY 40512-4116

MD and NCA BlueCard Correspondence
Mail Administrator
P.O. Box 14114
Lexington, KY 40512-4114

BlueCard Reimbursement
Once CareFirst receives the claim, it electronically routes the claim to the member's Blue Cross and Blue Shield Home Plan. After the member's home Plan processes the claim and approves the payment, you will receive payment from CareFirst.

Payment may not be sought from the member for any balances remaining after CareFirst's payment, unless it is to satisfy the member's deductible, copayment or coinsurance, or for services not covered under the member's Plan.

In some cases, a member's Plan suspends a claim because medical review or additional information is necessary. When resolution of claim suspension requires additional information from you, CareFirst may ask you for information or give the member's Plan permission to contact you directly.

NASCO

The National Account Service Company (NASCO) is exclusively available through Blue Cross Blue Shield (BCBS) Plans nationwide. NASCO offers solutions for administering traditional, point-of-service, preferred provider, HMO, dental, vision, prescription drug and other health services to national, regional and local employers. It allows national account customers to meet their market requirements for processing and administering health care benefits consistently for employees at numerous locations.

NASCO member identification

• Member identification cards issued by CareFirst have the CareFirst logo and "National Accounts" on the card.
• The membership number has a unique three (3) character alpha/numeric prefix.

NASCO claim submission

• Submit claims following the instructions that appear on the reverse side of the member's identification card.
• Submit the alpha/numeric prefix and the CareFirst provider number on all claims to ensure timely processing.
• Medical policy and claims processing guidelines may differ from CareFirst "local" business
• Many accounts follow Blue Cross Blue Shield Association (BCBSA) "national" medical policy, which may influence claims processing edits
• If no BCBSA medical policy exists, may default to "local" policy
• Claims processing edits and rules are approved by all Plans in the NASCO network.