Welcome | Table of Contents | Phone Numbers | Membership Information | Policy Statements | Administrative Functions
Administrative Functions
Provider Inquiries
There are four areas that service provider inquiries. Please refer to the "Important Telephone Numbers" section for a complete listing of how to contact CareFirst and where to send written correspondence.
Federal Employee Program (FEP) Dedicated Unit
The FEP Dedicated Unit services telephone and written provider inquiries for FEP employers and is comprised of a single unit that handles all specialties.
National Accounts Service and Claims Operations (NASCO)
The NASCO unit services telephone and written provider inquiries for most national accounts (employer accounts with offices in more than one state).
Provider Networks Management
Provider Networks Management assists providers with training and educational needs as well as distribution of written materials.
Patients should be instructed to contact the telephone number found on the front or back of their ID card or on their Explanation of Health Benefits (EOHB) after a claim has been processed.
Telephone Inquiries
The telephone service areas can assist your office with the following types of inquiries:
- Verification of patient eligibility
- Further explanation of specific benefits under a patient's coverage
- Request for review of payment on a processed claim
- Request to reopen a claim you feel has been denied in error
- Lost checks or vouchers
- Status of a previous inquiry to the service area
In order to expedite your call, please have the following information available when contacting one of the telephone service areas:
- Provider number
- Subscriber's name and membership number
- Patient's name
- Date(s) of service
- Charges
- Claim number (if already processed)
Written Inquiries
All of the areas servicing provider inquiries are equipped to respond to written inquiries. In order to initiate written correspondence please complete the Information Request Form (IRF). A free supply can be obtained by contacting the forms request line found in the "Important Telephone Numbers" section.
- The following information must be completed on each IRF to ensure a prompt reply:
- Account team letter (for local inquiries)
- Patient's name
- Patient's CareFirst membership number
- Provider number
- Date of inquiry
- Date of service
- If accident, the date of the accident
- 'Return to' information
- Reason for the inquiry
Helpful hints to speed your inquiry:
- Write legibly or type.
- Always attach a copy of the claim in question.Without a copy of the claim, a copy must be requested which will delay processing.
- For Medicare secondary claims, you may use the IRF to request a review of denied benefits, etc. However, if CareFirst has not processed the supplemental portion of the claim, please do not attach an IRF.
- If you are requesting a medical review of the claim determination or payment, attach copies of any pertinent medical records (operative notes, pathology report, etc.).
- Please request reviews of processed claims within six months of the determination. If you wait longer than six months, the information that we need to research the case may no longer be available.
Claims Submissions
In accordance with Maryland law addressing uniform claim form submission, all health care practitioners licensed or certified under the Health Occupation Article, Annotated Codes of Maryland must use the Centers for Medicare and Medicaid Services (CMS) 1500 as the standard claim form. In addition, providers should use the CMS instructions for completing the 1500 form when filing for professional services. To obtain the CMS 1500 form, please refer the CMS Web site.
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
10455 Mill Run Circle
Owings Mills, Maryland 21117-9921
Please include the membership number, patient name, claim number and the reason for the refund with your check. Make the check payable to CareFirst BlueCross BlueShield.
Timely Filing of Claims
To be considered for payment, claims must be submitted within 365 days from the date of service.
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 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.
Paper Claims Submission
Paper claims are scanned and a digitized version of the claim is produced and stored electronically. Successful imaging of the claim depends on print darkness. Light print produces unacceptable imaging and your claim may be returned to you. Please make sure to change typewriter ribbons or printer cartridges regularly so that the print is dark.
Incomplete claims create unnecessary processing and payment delays for all providers. The fields listed below must be completed on all claims submitted to CareFirst. Claims missing information in any of the following fields will be returned:
Block 1a: Insured's ID Number*
Block 2: Patient's Name
Block 3: Patient's Birth Date
Block 21: Diagnosis
Block 24a: Dates of Service
Block 24b: Place of Service
Block 24d: Procedures, Services or Supplies
Block 24f: Charges
Block 24g: Days or Units
Block 25: Federal Tax ID Number
Block 31: signature of Provider (including degree or credentials)
Block 33: Physician Billing information (enter your CareFirst Maryland region provider number** in the 'Grp#' area)
*The 3-digit prefix must be included if present on the subscriber's identification card. FEP membership numbers do not have a 3-digit prefix, but begin with an "R" and have 8 numeric digits.
**Use your 4-digit provider number with alpha characters (9999XX).
Claims must be submitted on an original (red/white) CMS 1500 form. Claims that are submitted on photocopies or forms other than an original CMS 1500 require manual input, which may result in processing delay. All information must be properly aligned within the blocks provided.
Sample CMS 1500 Form
Electronic Claim Submission
Electronic claims submission is the automated filing of claims utilizing a computer software package and transmitting the claims electronically. For information about becoming an electronic claim submitter, contact Maryland Health Information Network at 410-581-3583 or 800-441-1964.
Effective Follow-Up on Outstanding CareFirst BlueCross BlueShield Indemnity Claims
When a claim has been submitted and notification has not been received in your office after 30 days, you may wish to do follow-up research to determine the claim's status. The most effective way to follow-up on submitted claims is to check BlueLine to determine if the claims are processed.
DO NOT RESUBMIT CLAIMS WITHOUT CHECKING BlueLine, FIRSTLINE OR CAREFIRST DIRECT FIRST.
If there is no record of the original claim, the claim must be resubmitted. However, if the claim is pending in the processing system, a duplicate claim will only generate a rejection (duplicate of a claim already in process). A rejection will not cause the pending claim to be finalized and will cause a backlog of unnecessary claims to be processed.
Step-By-Step Instructions for Effective Follow-Up
Claim Status
The most effective way to accomplish follow-up on submitted claims is to:
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Access BlueLine, FirstLine, or CareFirst Direct (for local accounts & Federal Employee Program) or the appropriate dedicated national accounts (NASCO) unit to determine the status of the claim.
If there is no record of the claim, the claim must be resubmitted.
If the claim has been pending in the system for less than 30 days, wait until 30 days have elapsed from the processing date given on BlueLine, FirstLine, or CareFirst Direct. If processing has not been completed after 30 days, contact the appropriate provider customer service area.
Large Volume of Unpaid Claims
Please be sure that all vouchers and/or remittance tapes have been posted.
Use BlueLine to verify receipt and status of claims.
If you still have questions, please contact the appropriate provider customer service unit for assistance.
 Medicare Supplemental/Complementary
When the spin-off does not happen
Please allow approximately 30 days for the claim to be processed through the spin-off system after you receive the Medicare Remittance Notice. If processing from CareFirst does not occur in 30 days, please follow these steps:
Check BlueLine, FirstLine, or CareFirst Direct to verify that the claim has not been received by CareFirst. You do not need to wait 30 days from Medicare's processing date to check BlueLine, FirstLine, or CareFirst Direct. You may check any time after the receipt of a Medicare Remittance Notice.
If there is no record of the supplemental claim, please follow these steps:
Submit a copy of the Medicare Remittance Notice attached to a copy of the HCFA 1500 form. Be sure that the CareFirst provider numbers are indicated on the HCFA 1500 form appropriately.
Mail to the appropriate claims address.
- If the claim has been pending for more than 30 days, please contact the appropriate provider customer service unit for assistance.
Other Party Liability
Coordination of Benefits (COB)
COB is a cost-containment provision included in most group and member contracts that is designed to avoid duplicate payment for covered services. COB is applied whenever a member covered under a CareFirst contract is also eligible for health insurance benefits through another insurance company or Medicare.
If CareFirst is the primary carrier, full benefits are provided as stipulated in the member's contract. However, the member may 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. However, generally CareFirst's standard method of providing secondary benefits for covered services is the difference between the higher allowed benefit and the amount paid by the primary carrier as long as the difference does not exceed CareFirst's allowed benefit, except when Medicare is primary.
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 to recover payments made on behalf of a member/ subscriber 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.
Personal Injury Protection (PIP)
PIP is an automobile insurance provision that covers medical expenses and lost wages experienced by the insured or passengers as a result of an automobile accident. The minimum coverage is $2,500.While Maryland law was amended in 1989 to require this coverage for passengers and family members under the age of sixteen, most insureds choose to continue to cover other passengers under this provision in their automobile insurance contracts.
Workers' Compensation
This program is designed to provide reimbursement for workers who sustain injuries or illnesses arising out of or in the course of employment. Maryland's Workers' Compensation Act excludes sole proprietors, partners and officers of closed corporations from mandatory coverage under the act, giving them instead the option to elect coverage. Verification from the subscriber of this waiver is required by CareFirst in order to process claims.Workers' compensation replaces health insurance. A participating provider cannot balance-bill CareFirst or the subscriber for any amount not covered under workers' compensation. Claims for workers' compensation should be filed to the workers' compensation carrier first and to CareFirst only after the workers' compensation carrier has determined that the charges are non-compensable under workers' compensation. If workers' compensation determines that the charges are non-compensable, attach a copy of the denial from the workers' compensation carrier to the claim.
Appeal Process
A participating provider may appeal a decision in writing within 180 days from the date of notification of the denial. All appeals can be submitted on an Provider Inquiry Resolution Form (PIRF) (122KB, 2 pgs.)  or electronically, via CareFirst Direct.*
*This appeal process does not include the provider inquiry process for an FEP member. FEP membership numbers begin with the letter "R".
Claims Issues/Initial Contact to the Plan
The provider should contact Provider Services at 410-581-3581 or 800-437-2332 to inquire about a claims payment dispute. Some inquiries can be handled to the satisfaction of the provider in the appropriate Provider Services area. If the inquiry cannot be satisfied in the Service area, the provider will be instructed to make the appeal in writing and submit this information, along with any pertinent or supportive medical record, literature or claims documentation, to CareFirst BlueCross BlueShield.
Internal Appeal Process
The appeal must be filed within 180 days from the date of notification of the denial or claims payment dispute. CareFirst may require additional information from the provider. All appeal and grievance decisions are answered in writing. There is an emergency/expedited review process available to you. These inquiries will be responded to within 24 hours of the request to CareFirst. An emergency includes a service not yet provided (i.e., a prospective service that is not yet a claim.)
Necessary Information
A letter describing the reason(s) for the appeal or grievance and the clinical justification/rationale is required, including the following information, if possible:
- Patient name and identification number
- Provider number or tax identification number
- Admission and discharge date (if applicable) or date(s) of service
- Physician name
- A copy of the original claim
- Supporting clinical notes or medical records including, as an example, pertinent lab reports, x-rays, treatment plans, progress notes, etc.
The following information is available on our Web site:
Appeals and grievances should be forwarded in writing to the appropriate Provider Services area address:
Mail Administrator
P.O. Box 14114
Lexington, KY 40512-4114
Participating Provider Agreement (PAR)
The major terms of the PAR agreement require that the provider:
File claims on behalf of the member
Only request deductibles and copayments at the time of the service
Accept the allowed benefit as payment in full
The provider will receive reimbursement directly from CareFirst on their remittance.
Eligibility
Most licensed health care professionals are eligible to participate. Please contact the Networks Development Department with eligibility questions (see Important Telephone Numbers).
Reimbursement Allowances
Participating providers agree to accept the Allowed Benefit or 'AB' as determined by CareFirst. This means that participating providers cannot bill the subscriber/patient for the difference between their charge and the Allowed Benefit for covered services. Participating providers may bill subscribers for deductibles, coinsurance and copayments up to the Allowed Benefit at the time of service. The subscriber/patient may be billed in full for non-covered services.
Providers cannot require the payment of charges above and beyond coinsurance, copayments and deductibles. To help you evaluate your office’s current practices, our policy is below.
- Participating providers shall not charge, collect from, seek remuneration or reimbursement from or have recourse against subscribers or members for Covered Services, including those that are inherent in the delivery of Covered
Services. The practice of charging for office administration and expense is not in accordance with the Participation Agreement and Participating Provider Manual. Such charges for administrative services would include, by way of example, annual or per visit fees to offset the increase of office administrative duties and/or overhead expenses, malpractice coverage increases, writing prescriptions, copying and faxing, completing referral forms or other expenses related to the overall management of patients and compliance with government laws and regulations, required of health care providers.
- However, the provider may look to the subscriber or member for payment of deductibles, co-payments or coinsurance, or for providing specific health care services not covered under the member’s Health Benefit Plan as well as fees for some administrative services. Such fees for administrative services may include, by way of example, fees for completion of certain forms not connected with the providing of Covered Services, missed appointment fees, and charges for copies of medical records when the records are being processed for the subscriber or member directly.
- Fees or charges for administrative tasks, such as those enumerated above, may not be assessed against all members in the form of an office administrative fee, but rather to only those members who utilize the administrative service.
Preferred Provider Agreements (PPN)
Participating providers are also eligible to become Preferred Providers. Major provisions of the Preferred Provider Agreement include:
Submit all claims directly to CareFirst
Accept the Preferred Provider Allowed Benefit as payment in full
Bill CareFirst members only for deductibles, copayment, coinsurance, and non-covered services
Direct care of PPN patients to other PPN providers
Notify CareFirst if an out of network referral is required
Ensure that the managed care provisions of the contract are met
Eligibility
Preferred providers must meet the credentialing standards of CareFirst.
Reimbursement
Preferred providers agree to accept a Preferred Provider Allowed Benefit (PPAB) as payment in full. Preferred providers may not bill the patient for amounts that exceed the PPAB for covered services. Subscribers are liable for non-covered services, deductibles, copayments and coinsurance.
Changes in Provider Information
CareFirst health care providers who need to change their provider information should use a 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
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.
Remember if you change your Tax Identification number you will be issued a new Carefirst provider number, and a new provider packet. We realize that you are not a new provider, but you must use the new Carefirst provider number when required.
Termination of Agreement
Under the terms of the current provider agreements, providers must provide written notification of termination with 60 days notice.
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