CareFirst Essentials
Learn more about who we are, what we offer and how to work with us.
Featured Course
We recommend new providers begin with “Working with CareFirst". This course is all about who we are and how to do business with us. It covers our mission, participation agreements, provider resources, provider self-service and provider support.
Select a category to expand:
Video | 15 minutes | All Providers
Welcome to CareFirst! View this video to learn about who we are and how to do business with us.
- CareFirst Mission
- Network Participation
- Provider Support
- Resources Available
How to Determine Which CareFirst Networks You Are In
Interactive Guide | 8 minutes | All Medical Providers
Unsure of which networks you participate in? This guide is for you!
- Importance of knowing the networks you participate in
- How to access the provider directory
- How to determine which network(s) you participate in
CareFirst Networks for Medical Providers
Self-paced Module | 10 minutes | All Medical Providers
All about our networks for medical products- Core Networks: HMO and PPO
- Expansion Networks: Blue High Performance NetworkSM (BlueHPNSM) and BlueEssential
- Government Programs Network: Medicaid and Medicare Advantage
- Network Participation
- Find a Doctor Tool
How to Read NOPs for Medical Providers
Self-paced Module | 10 minutes | All Medical Providers
A snapshot of the information included on a medical Notice of Payment.
- Explanation of a Notice of Payment (NOP)
- Review of the front page of an NOP and the information you can find
- Review of the detailed claim information found in the NOP
- Review of the summary page
- Review of the remark codes
Self-paced Module | 15 minutes | All Providers
What does it mean that CareFirst is part of the BlueCross BlueShield Association? How do the companies within the BCBSA interact?
- What is the BlueCross Blue Shield Association (BCBSA)?
- The role CareFirst plays as part of the BCBSA
- How companies within the BCBSA interact
- How CareFirst connects through BlueCard
Self-paced Module | 10 minutes | All Providers
An overview of health insurance claims and what happens when a claim is submitted.
- Overview of HIPAA and PHI
- Privacy and security regulations at CareFirst
- Importance of patient data protection
- Best practices for data protection
- Additional information and support
Self-paced Module | 10 minutes | All Medical Providers
An overview of our interactive voice response (IVR) system.
- Explanation of CareFirst on Call
- How to access CareFirst on Call
- CareFirst on Call features
- How to use this self-service tool
Accessing the Authorizations Home Page
Video | 8 minutes | All Medical Providers
A look at how to get to the authorization system.
- The different ways to access the authorization home page
- How CareFirst Direct seamlessly integrates with the authorization system
- An overview of the authorization tiles
- Where to find authorization policies and resources
Video | 15 minutes | All Medical Providers
Things you should know before you start using the authorization system.
- The system’s basic requirements
- Information on Smart Search and Advanced Search
- General authorization basics
- Accessing messages in the authorization system
Authorization Frequently Asked Questions
Interactive Guide | 10 minutes | All Medical Providers
Still have questions about the authorization system? Refer to this FAQ document.
- Information on system functionality
- Billing information
- Information on clinical notes and authorizations
Authorization System Features and Additional Information
Interactive Guide | 12 minutes | All Medical Providers
Additional information about working in the authorization system.
- Overview of the authorization system information
- Withdrawing pended authorizations
- Viewing and responding to messages
- Locating historical authorizations
- Resources and additional information
Finding Members in the Authorization System
Video | 2 minutes | All Medical Providers
A look at how to find members within the authorization system.
Finding Providers in the Authorization System
Video | 2.5 minutes | All Medical Providers
A look at how to find providers within the authorization system.
Genetic Testing Prior Authorizations
Self-paced Module| 10 minutes | All Medical Providers
Need to submit a prior authorization for genetic testing? Check out this module!
- Overview and guidelines for Genetic Testing prior authorizations
- Step-by-step instructions on how to submit a prior authorization for Genetic Testing
- Clinical review process and case closure rules
How to Determine if an Authorization is Required
Interactive Guide| 10 minutes | All Medical Providers
Not sure if a benefit requires an authorization? Here is a guide to determine if it does.
- Overview of prior authorizations
- Steps to determine if a benefit requires authorization
- Authorization resources available
How to Edit Dates of Service in the Authorization System
Interactive Guide| 3 minutes | All Medical Providers
A step-by-step guide to editing dates of service within the authorization system. This option is available for authorizations that are in either an Approved or Pending status.
MCG User Interface Walk-Through
Interactive Guide| 5 minutes | All Medical Providers
A guide on how to correctly utilize the MCG User Interface within the authorization/notification portal:
- Successfully add clinical documentation within the MCG user interface
- Identify when MCG guidelines are not required or do not apply for your request
- Ensure the 'Submit Request' button is selected on all requests
Medication Prior Authorization
Interactive Guide| 10 minutes | All Medical Providers
How to enter electronic pharmacy authorizations and NCCN Regimen authorizations.
- How to access the medication authorization system
- Steps to enter a medication authorization
- Steps to enter a NCCN Regimen authorization
Uploading Clinical Documentation
Interactive Guide | 5 minutes | All Medical Providers
A guide on how to upload clinical documentation to prior authorizations in progress.
- Accessing the authorization system through the Provider Portal (CareFirst Direct)
- Locating the authorization(s) you need
- Uploading clinical documentation to authorizations
Withdrawing Pended Authorizations
Video | 5 minutes | All Medical Providers
A look at how to withdraw pended authorizations.
- How to search for the authorization
- How to withdraw the pended authorization
- How to confirm the authorization is withdrawn
Entering Inpatient Authorizations
Video | 15 minutes | All Medical Providers
A tutorial on entering inpatient authorization requests.
- Steps to enter an inpatient authorization
- How to complete the MCG questionnaire
- How to find the authorization decision status
- Adding additional information to approved or pending status authorizations
Entering Inpatient Authorizations
Interactive Guide | 15 minutes | All Medical Providers
A guide on entering inpatient authorization requests.
- Overview of the authorization system information
- Information required to enter an authorization
- Steps to enter an inpatient authorization
- How to complete the MCG questionnaire
Video | 12 minutes | All Medical Providers
A tutorial on entering outpatient authorization requests.
- Steps to enter an outpatient authorization
- How the authorization system integrates with MCG guidelines
- How to find the authorization decision status
- Adding additional information to approved or pending status authorizations
Entering Outpatient Authorizations
Interactive Guide | 20 minutes | All Medical Providers
A guide on entering outpatient authorization requests.
- Overview of the authorization system information
- Information required to enter an authorization
- Steps to enter an outpatient authorization
- How to complete the MCG questionnaire
- Steps to request an outpatient extension
Requesting Outpatient Extensions
Video | 5 minutes | All Medical Providers
All about how to request an outpatient extension.
- What state an authorization must be in to be extended
- The steps to request an outpatient authorization
- How to confirm the status of your request
CareFirst Administrators (CFA)
Self-paced Module | 10 minutes | All Medical Providers
This module will describe who CFA is, how it operates in the Third Party Administrator (TPA) space, the services it provides, how to identify its members and file claims and the CFA BlueChoice Advantage Hybrid product.
Are you a Dental or PCMH provider? Access more CareFirst Direct courses specialized for you in the Dental and Practice and Payment Transformation course suites.
Claim Inquiries in CareFirst Direct
Interactive Guide | 5 minutes | All Medical Providers
Not sure how to submit a claim inquiry in the portal? Check out this guide.
- What is an inquiry?
- What is timely filing for inquiries?
- Submitting FEP and Facet claim inquiries
- Submitting NASCO and BlueCard claim inquiries
Accessing Fee Schedules in CareFirst Direct
Interactive Guide | 5 minutes | All Medical Providers
Need to locate fee schedules? This guide is for you!
- What are fee schedules?
- Access requirements to view fee schedules
- Searching fee schedules by commonly billed procedure codes
- Searching fee schedules by a procedure code search
- How to view PDF results
Checking Eligibility and Benefits in CareFirst Direct
Interactive Guide | 8 minutes | All Medical Providers
Need help locating eligibility and benefits information on CareFirst Direct? This guide is for you!
- Information to keep in mind
- Review of the Eligibility Summary screen
- How to search general or specific benefits
- Review benefit details and authorization requirements
- How to add benefits to your favorites
Checking Claim Status in CareFirst Direct
Interactive Guide | 5 minutes | All Medical Providers
Not sure how to check claim status? Check out this guide.
- Information to keep in mind
- How to search different date ranges
- Viewing Claim Status Results
- Viewing Claim Status Summary
- Viewing claim line information
Electronic Remittance (835) for Medical Providers
Interactive Guide | 5 minutes | All Medical Providers
A walkthrough of 835 remittance on CareFirst Direct.
- Access requirements to view remittance/NOP
- Accessing the remittance/NOP tab
- How to search for remittance
- Viewing search results
- Viewing remittance details and claim information
Provider Directory Update and Attestation
Interactive Guide | 15 minutes | All Providers
A guide to updating and attesting directory information in compliance with the Consolidated Appropriations Act (CAA).
- Overview of the Consolidated Appropriations Act and it’s mandates for Provider Directory information
- Complete practice update and attestations
- Complete practitioner updates and attestations
- Requesting demographic information access
- Approving or assigning demographic information
- Provider Directory tutorial
Multifactor Authentication in CareFirst Direct
Interactive Guide | 5 minutes | All Providers
A guide to setting up and changing multifactor authentication methods in CareFirst Direct.
- Setting up multifactor authentication for new users
- Adding multifactor authentication for existing users
Creating a New User in CareFirst Direct
Interactive Guide | 5 minutes | All Providers; Portal Administrators
Need to create a new user for your organization? Check out this guide.
- Locate User Management
- Create a new user
- Review of the new user’s next steps
Resetting a Password in CareFirst Direct
Interactive Guide | 5 minutes | All Providers; Portal Administrators
This guide will review how to reset a password for CareFirst Direct.
- How to access User Management
- How to Access a User’s profile
- Process to reset a password
Locking and Unlocking an Account in CareFirst Direct
Interactive Guide | 5 minutes | All Providers; Portal Administrators
Check out this guide to lock or unlock a user account.
- How to access User Management
- How to Access a User’s profile
Adding Access to a Current User in CareFirst Direct
Interactive Guide | 5 minutes | All Providers; Portal Administrators
This guide will review how to add access to a current user.
- Overview of standard user access
- How to Access a user’s profile and current access
- How to add/remove access to a user’s profile
- Viewing and approving/denying user requests for access
Terminating an Account in CareFirst Direct
Interactive Guide | 5 minutes | All Providers; Portal Administrators
Check out this guide on how to terminate a user’s account.
- Important overview information
- How to Access a user’s profile
- Review of the termination process
Managing User Access Requests in CareFirst Direct
Interactive Guide | 15 minutes | All Providers; Portal Administrators
Not sure how to complete user access reviews? Review this guide.
- Importance of user access reviews
- Review of the User Management notifications
- How to complete new user requests
- How to complete additional access requests and access reviews
- How to assign user administrators
- Review of additional user management features
Accessing and Registering for CareFirst Direct
Interactive Guide | 5 minutes | All Providers
Want to access your organization’s claim information, eligibility and benefits, and more online? Review this guide.
- Benefits of registering for the portal
- Registration process for users
Updating Your Profile in CareFirst Direct
Interactive Guide | 5 minutes | All Providers
How to update your user profile in the portal.
- How to update your name, contact information, and password
- How to view current access and request additional access
- How to review the terms of use
Self-paced Module | 5 minutes | All Medical Providers
What you need to know when filing BlueCard claims.
- Explanation of the BlueCard program
- Important information about the prefix
- Steps to file a claim
- Member ID card tips and examples
Corrected Claims, Inquiries and Appeals
Self-paced Module | 15 minutes | All Medical Providers
Should you submit a corrected claim, inquiry or appeal? Take this module to find out!
- What an appeal is and how to submit it
- Guidelines for standard and expedited appeals
- What a corrected claim is and ways to submit it
- How to follow up on corrected claims
- What an inquiry is
- Guidelines for submitting an inquiry
- Electronic and paper inquiry submissions
Mother and Baby Billing Guidelines
Interactive Guide | 5 minutes | All Commercial Medical Providers
A description of the billing guidelines governing mother and baby claims for Commercial accounts.
Submitting Claims for Medical Providers
Self-paced Module | 10 minutes | All Medical Providers
All you need to know about CareFirst claims submission procedures.
- Electronic and paper claim submission requirements
- Authorization and referral requirements
- Other party liability and coordination of benefits
- Electronic capabilities
CareFirst Products: BlueChoice
Self-paced Module | 20 minutes | All Medical Providers
A deep-dive into BlueChoice and our Health Maintenance Organization (HMO) products.
- Key requirements of BlueChoice products
- Vendors of BlueChoice products
- BlueChoice plans and their defining features
- Member ID card examples for each BlueChoice product
CareFirst Products: Other Products
Self-paced Module | 25 minutes | All Medical Providers
An overview of more CareFirst products.
- Preferred Provider Organization (PPO)
- Exclusive Provider Organization (EPO)
- Maryland Point of Service (MPOS)
- Federal Employee Program (FEP)
- MedPlus Medigap and Medicare Advantage
- Consumer Directed Health (CDH)
Individual Medicare Advantage (HMO)
Self-paced Module | 10 minutes | All Medical Providers
Need some information on our Medicare Advantage HMO plans? Check out this module!
An overview of the CareFirst BlueCross and BlueShield and CareFirst BlueChoice, Inc. (collectively "CareFirst") Individual Medicare Advantage (Medicare Advantage HMO) plans.
Self-paced Module | 25 minutes | All Medical Providers
An overview of the CareFirst BlueCross BlueShield Group Medicare Advantage plans.
- Group Medicare Advantage (MA) service area
- Group MA network and network sharing process
- Product and benefit structure
- Locating benefits and eligibility in CareFirst Direct
- Process for submitting authorizations and care management
- Claims and appeals process
Blue High Performance NetworkSM (BlueHPNSM)
Self-paced Module | 15 minutes | All Medical Providers
A deep-dive into our BlueHPN product and network.
- BlueHPN overview
- Product network and participation information
- Benefits of the BlueHPN product
- Identifying BlueHPN members
- Eligibility and benefits
- Claim submission
Medicare Advantage (MA) HMO Referral Training (for MA HMO Providers)
Self-paced Module | 10 minutes | All Medical Providers
An overview of CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (collectively "CareFirst") Medicare Advantage (MA) HMO referral policy, and how you can identify in-network providers for referrals.
- Review the CareFirst referral policy for MA HMO members
- Demonstrate how to identify in-network providers for referrals
- Provide additional resources to answer your referral questions
Self-paced Module | 15 minutes | All Medical Providers
An overview of the CareFirst BlueCross and BlueShield and CareFirst BlueChoice, Inc. (collectively "CareFirst") Away from Home Care program, who qualifies for it, and how claims are processed.
- What is Away from Home Care?
- Who qualifies for the program?
- How does the Away from Home Care Program work?
- How are claims processed for the program?
Self-paced Module | 20 minutes | All Medical Providers
An in-depth overview of the BlueCard program.
- Types of products BlueCard supports
- How to identify BlueCard members
- Verifying eligibility, submitting claims and checking claim status for BlueCard
- Obtaining prior authorization and medical policy for BlueCard members
- Claims appeal and inquiry process for BlueCard
- Contact information for BlueCard questions
Self-paced Module | 10 minutes | All Medical Providers
An overview of contiguous county claim filing.
- Quick review of BlueCard
- Definition of contiguous areas
- Guidance on claims
- Sample contiguous area claims filing scenarios
Self-paced Module | 15 minutes | All Medical Providers
An overview of the programs offered at CareFirst.
- National Account Service Company (NASCO)
- BlueCard
- Third Party Administrators (TPA)
- CareFirst Administrators
- Disease Management Programs
- Pregnancy Care Incentive Program