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Becoming an Electronic Submitter | EDI Manuals | Provider ID Numbers & Payer Codes | Hints for Successful Submission | Frequently Asked Questions | Contact Information
How does the electronic submission process work?
- Providers send electronic claims to CareFirst through one of our preferred vendors/clearinghouses.
- The vendor/clearinghouse will edit all claims and send you a report to notify you of any errors they identify. Errors must be corrected and the claims must be resubmitted electronically.
- Claims without errors are forwarded to CareFirst for processing and additional editing.
- You will receive an additional report from the clearinghouse to confirm receipt of claims by CareFirst and advise you of any additional errors. Again, you have the opportunity to correct all errors and resubmit claims electronically.
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How does my office begin submitting claims electronically to CareFirst?
- If you do not currently have a vendor or clearinghouse, you may contact one of our preferred vendors.
- If you currently work with another vendor or clearinghouse, you must contact that vendor to inquire about the enrollment process.
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What information does a vendor or clearinghouse need to submit claims electronically to CareFirst?
A vendor/clearinghouse will need your Maryland and/or NCA Provider ID number
- Use your Maryland provider ID number to submit claims for the following Maryland-based products:
- Maryland Point of Service (MPOS)
- Preferred Provider Organization (PPO)
- Preferred Provider Network (PPN)
- All other Maryland indemnity products
- NASCO- MD
- Use your NCA provider ID number (i.e., Group Hospitalizations and Medical Services, Inc. or CareFirst BlueChoice, Inc. provider ID number) to submit claims for the following NCA-based products:
- Federal Employee Program (FEP)
- CareFirst BlueChoice HMO, CareFirst BlueChoice Open Access, CareFirst BlueChoice Opt-Out Open Access, CareFirst BlueChoice Opt-Out Plus, and CareFirst BlueChoice Opt-Out Plus Open Access
- BluePreferred
- NASCO - NCA
- All other NCA indemnity products
In addition to your provider ID number, your vendor/clearinghouse is required to submit claims to CareFirst and CareFirst BlueChoice using electronic payer codes. There are separate payer codes for professional and institutional claims. Please contact your vendor/clearinghouse to confirm the appropriate codes.
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Is there a telephone number that I can call regarding problems with my electronic claim submissions?
Please direct questions to your vendor or clearinghouse first. If you need further assistance, contact the CareFirst EDI team at 410-998-4599 or send an e-mail to hipaa.partner@carefirst.com.
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A Maryland professional claim was returned to me with the error message 'Plan Profile Not Found.' What does this mean?
This error will occur when the prefix sent is not recognized as "valid". Please check to make sure it was entered correctly. If it was entered correctly, contact Provider Services at 410-581-3581 or 800-437-2332 to verify that it is a "valid" prefix.
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I am a specialist. Can I send referrals electronically for Maryland Point of Service (MPOS) members?
At this time, referrals cannot be sent electronically for MPOS members. The primary care physician should mail a copy of the patient's referral at the time it is written. If you are experiencing problems because the referral is not on file when your claim is processed, please continue to send your claims electronically but also fax a copy of the referral to the MPOS Claims Unit at 410-998-5741.
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I am a specialist. Can I send referrals electronically for CareFirst BlueChoice* patients?
Yes. You must include the following information:
- Referring provider first and last name
- Referring provider CareFirst BlueChoice provider number (4 character group number + 4 digit member number)
- Date of referral and number of visits indicated on the referral
- Referral number found on the referral form (RE = 7 digits) or, if the PCP used a Uniform Consultation Referral Form, enter RE0000001
* A written referral is not required for members with CareFirst BlueChoice Opt-Out Open Access.
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Do I have to include a date of onset* on all claims?
No. The date of onset is required only on claims containing a diagnosis in one of the following categories:
Medical Emergency
- Date of onset is required on Maryland claims only.
- For a list of diagnosis codes, visit the Medical Policy section of www.carefirst.com, section 10; policy number 10.01.11A.
Accidental Injury
- Accident date is required on Maryland and FEP claims only.
- Accident indicator code must be included .
- The diagnosis code range is V015, 52511 and 800 - 9998.
Maternity
- Last menstrual period (LMP) date is required on Maryland claims only.
- Symptom indicator code must be included.
- The diagnosis code range is 630 - 677, V22 - V242, V27 - V279, V28 - V289, V615 - V617 and V724.
*Note: The date of onset requirements, under any category, do not apply when the biller is an independent laboratory.
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