Indemnity Provider Manual - Maryland

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Membership Information

Membership Identification Cards

MPOS	CareFirst Maryland Indemnity
State of Maryland (PPN)	DC Indemnity
NASCO	NCA Indemnity Traditional
Federal Employee Program (FEP) - Standard Option	Federal Employee Program (FEP) - Basic Option

Traditional Products

This product provides benefits based on the allowed benefit. Participating providers are required to accept the allowed benefit as payment in full. Subscribers can only be billed for deductibles, copayments and non-covered services. Subscribers may carry Major Medical coverage in addition to Plan C.

Types of benefits provided under this plan include but are not limited to:

• Inpatient medical care
• Surgical coverage
• Diagnostic services-as part of the diagnostic endorsement

Types of benefits provided under Major Medical include but are not limited to:

• Office visits
• Outpatient mental health
• Physical therapy
• Durable medical equipment

Preferred Provider Products

Under the terms of Preferred Provider Products, members have less out-of-pocket expense when a preferred provider renders care.When care is rendered by a non-preferred or out-of-network provider, benefits will be provided, in most cases, but the member will be responsible for deductibles and coinsurance. CareFirst offers two preferred provider products: preferred provider network (PPN) and preferred provider organization (PPO).

PPN

A PPN is a provider-driven program. This means that in addition to the terms of the participating agreement, the provider has agreed to:

• Ensure that all managed care provisions of the contract are met
• Direct care to other PPN providers
• Contact CareFirst if an out-of-network referral is medically indicated (contact the referral unit)

PPO

A PPO is a subscriber driven program. This means that the subscriber agrees to:

• Stay within the Preferred Provider Network
• Adhere to the managed care provisions of the contract

Medicare Supplemental Products

CareFirst offers a variety of Medicare supplemental policies to compliment Medicare benefits. These policies are offered through group contracts as well as directly to individual subscribers.

TEFRA

The Tax Equity and Fiscal Responsibility Act (TEFRA) is legislation enacted by the federal government which specifically states that an active employee age 65 and over, or the spouse (the Deficit Reduction Act-or DEFRA- is an amendment to TEFRA which stipulates that spouses fall under TEFRA) age 65 and over of an active employee, may enroll in the same group coverage offered to younger employees and their spouses. In instances where the employee or spouse has elected the group coverage, CareFirst is the primary carrier to whom the claim should be submitted first, Medicare is the secondary carrier. After CareFirst has processed the claim, it will be necessary to forward the claim to Medicare. CareFirst does not automatically forward claims to Medicare.

Network Claims Product

CareFirst is jointly administering the Network Claims product with third-party administrators (TPAs), self-insured employers, and health and welfare funds. Because CareFirst shares administrative tasks with these entities, employers are able to access CareFirst's provider networks, design health benefits, and share financial responsibilities. CareFirst is responsible for training and maintenance of the provider network and collecting and pricing claims.

Patient information

Patients enrolled in this program can be identified in several ways:

• A unique identification card bears the CareFirst logo and the logo of the account or third party administrator
• The prefix on the identification card begins with 'A' followed by two numeric characters
• Identification cards, EOBs, checks and vouchers will usually have CareFirst's and the account's logo

How should providers submit claims?

Providers should submit claims following the instructions that appear on the reverse side of the patient's identification card. The patient's alpha/numeric prefix and the CareFirst provider number must be submitted on all claims to ensure timely processing.

Claims can be submitted electronically or on paper, as identified in the CareFirst participating agreement. Participating providers agree to accept the CareFirst allowed benefit as payment in full for services rendered to these patients, less any deductibles and coinsurance amounts.

To obtain information about benefits, claim status, claim adjudication, deductibles, or coinsurance, please call the provider service number on the back of the patient's identification card.

Maryland Point of Service

Primary Care Physician

Internists, family practitioners, and pediatricians are eligible to contract with CareFirst to become primary care physicians under the Maryland Point of Service (MPOS) product.Members 13 years of age and older may select an internist as a PCP as long as the PCP has no self-imposed age restrictions. Members up to age 21 may select a pediatrician as a PCP as long as the PCP has no self-imposed age restrictions. The member chooses a PCP during open enrollment and may change PCPs at any time during the year. If a PCP is not selected, one will be automatically assigned. The PCP is responsible for managing and coordinating all of the member's health care needs.

Specialist/Referral

When specialty care is required, the PCP writes a referral using the Maryland Uniform Consultation Referral form to a specialist within the preferred provider network. The referral must be completed by the PCP for the member to receive maximum benefits. The specialist cannot refer the member to another provider, as this would raise the out-of-pocket expense for the member. If additional care is required, the specialist should confer with the PCP, and the PCP will determine what course of action to take. PCPs should mail, phone, or fax the referral to CareFirst as soon as possible to avoid out-of-network processing of the specialist's claim.

Referrals are valid for a minimum of 120 days, unless otherwise stated. Specialists should verify the validity of a referral prior to rendering services.

Referrals for inpatient services can be taken by telephone by Utilization Management. The PCP must call with the information.

Direct Access

Generally certain services can be obtained without a referral from the PCP and still be processed as in-network services. Services such as these are referred to as direct access services. Please keep in mind that benefits for these services would still need to be verified by the appropriate provider service area. They are:

• Accidental care
• Ambulance services
• Artificial insemination/in-vitro fertilization performed by PPN specialist
• Hospice care
• Human organ transplant
• Emergency
• Most outpatient diagnostic, machine and laboratory testing and radiological service (except MRI, CAT scan, Holter Monitor, and interventional radiology)
• OB/GYN services rendered by a PPN OB/GYN or Nurse Midwife in his or her office

Most psychiatric and substance abuse care should be referred through Magellan Behavioral Health.

Claims/Benefits

Claims may be submitted electronically or on paper. Paper claims are to be submitted to the normal CareFirst address.National account paper claims should be submitted to the CareFirst NASCO address.

For benefit information, contact BlueLine, FirstLine, CareFirst Direct or Provider Services (see Important Telephone Numbers).

Some of your patients may have a product known as Triple Choice. Level one this product provides the highest level of benefits and the services are provided or referred by the PCP. Level two services are performed by a PPN provider without a referral. Level three services are rendered by a CareFirst participating provider or non-participating provider and offers the lowest level of benefits.

BlueCard Program

CareFirst along with the Blue Cross Association in Chicago implemented the BlueCard Program. Providers who participate with CareFirst's Maryland provider network should accept all Blue Cross Blue Shield (BCBS) members regardless of which BCBS plan maintains the patient's enrollment.Providers who participate with CareFirst's Maryland provider network should accept all Blue Cross Blue Shield (BCBS) members regardless of which BCBS plan maintains the patient's enrollment.

Programs that are not affected by BlueCard:

Federal Employee Program,Medicare Secondary, Maryland Dental Program, Vision Program, Pharmacy Program, CareFirst's HMOs including the HMO Opt-Out policies.

Providers located in Maryland should file claims based on the following:

• Provider is participating with CareFirst's Maryland network only:
  Claims for all BCBS subscribers, regardless of the BCBS plan that they are enrolled through, must be submitted to CareFirst.
• Provider is a Preferred Provider with CareFirst's Maryland network and the National Capital network and the member has a PPO/PPN contract:
  Claims should be submitted to the plan where the subscriber has membership.
• Provider is a Preferred Provider with CareFirst's Maryland network only or the National Capital network only and the member has a PPO/PPN contract:
  Claims should be submitted to the plan where the practitioner holds a PPO/PPN contract.
• Claims for CareFirst subscribers who hold a Maryland membership card and subscribers of BCBS plans that the provider does not participate with must be submitted to CareFirst.

The BlueCard program also requires that participating providers bill the patient only for their share (deductibles, copayments, and coinsurance amounts) of covered services based on CareFirst's allowed benefit. All BCBS plans have issued their subscribers membership identification cards that contain a 3-letter membership number prefix (excluding Federal Employee Program, Medicare Secondary, Maryland Dental Program, and CareFirst's HMOs). The BCBS Association assigned the first two positions (or letters) of the prefix. Each BCBS plan assigns the third position of the prefix.Most plans have taken advantage of the ability to assign the third letter and use it to assist with claims direction and contract identification. CareFirst's Maryland membership numbers will begin with the letters XW, CareFirst of DCs prefixes begin with an XI. It is critical to claims processing for out-of-state subscribers that the prefix appears on the claim form. The prefix should be obtained from the subscriber's identification card, when possible. Include the prefix for both paper and electronic claims. If you are not certain where to indicate the prefix when filing electronically, please contact your software vendor.

Where to Direct Inquiries

• Benefits and eligibility can be verified by contacting the plan through which the patient is enrolled. You can do this by calling toll free 800- 676-BLUE (800-676-2583) where you will be directed to the appropriate BCBS plan. You must obtain the 3-letter prefix in order to use this number.
• Claim status inquiries can be directed to CareFirst. You can contact BlueLine, FirstLine, CareFirst Direct, or the Provider Service Area.