Provider Manual - CareFirst

1 Provider ManualFor our institutional Provider communityTable of ContentsThis Manual provides information for your CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. ( CareFirst ) the terms of the Participation Agreement, all providers are required to adhere to all policies and procedures contained in this Manual , as we make any procedural changes, in our ongoing efforts to improve our service to you, we will update the information in this section and notify you through email and BlueLink, our online Provider requirements of a member s health benefits vary and may differ from the general procedures outlined in this Manual .

2 If you have questions regarding a member s eligibility, benefits or claims status information, we encourage you to use one of our self service channels; CareFirst Direct or CareFirst on Call. Through these channels, simple questions can be answered quickly. Read and print the Guidelines for Provider Self of ContentsProvider Quick Reference GuideAdministrative FunctionsInstitutional credentialingAdditional credentialing resourcesVerify Provider information requirementCareFirst Direct & CareFirst on CallInpatient notification and outpatient prior authorizationsInpatient notificationOutpatient prior authorizationsAppealsServices requiring an authorizationTimely filing of claimsReconsiderationDocumentation necessary to prove timely filingHow to submit claims with denied chargesElectronic capabilitiesElectronic

3 ClaimsElectronic Remittance Advice (ERA)Electronic Fund Transfer (EFT)Special claims submission informationObservation servicesGuidelinesMother and baby claimsDiagnosis Related Group (DRG)Network claims productMedicare supplemental productsFederal Employee Program (FEP) coordination of benefitsNotification of denialNon DRG reimbursement cases (MD only)Table of ContentsRemittanceRefunding erroneous paymentsMethods of reimbursementHealth Insurance Portability and Accountability Act (HIPAA)Standard reimbursement methodologyExemptions to standard pricing methodologyParticipating hospitals in MarylandDRG inpatient payment methodologyDRG reimbursement casesOutpatient hospital payment methodologyFree standing ASC payment methodologyHospice reimbursement methodologyMiscellaneous payment provisions to the master agreementMembers to be held harmlessPayment periodThird party paymentsAdjustmentsOff-set of overpaymentUtilization Review (UR)

4 ProgramInquiries and appealsGeneral inquiriesInstructions for submitting an inquiryHelpful tips when completing a Provider Inquiry Resolution form (PIRF)Corrected claimsAppealsInstructions for submitting an appealClinical Appeals and Analysis Unit (CAU)Clinical appeal checklistExpedited or emergency appeals processAppeal resolutionAppeal contact informationOther party liabilitySubrogationPersonal Injury Protection (PIP) no fault automobile insuranceWorkers compensationQuality Improvement (QI)Performance dataMother and Baby Claims Billing GuideFor non FEP accountsFor FEP accountsReminders for all.

5 Care ManagementCare management indemnity and Health maintenance Organization (HMO)Hospital Transition of Care program (HTC) Coordinated home care and home hospice care Complex case management (CCM)Behavioral health and substance use disorder program (BSD)Intake, assessment and appointment (IAA)Services requiring prior authorization CareFirst BlueChoiceInpatient hospitalization services indemnity and CareFirst BlueChoicePre-admission certification process for elective admissionsEmergency admission certification processConcurrent review processIndemnity and HMO retrospective review process Discharge planning process indemnity and HMOO utpatient hospitalization servicesCase management referral process indemnity and HMOD isease management programsTable of ContentsPM0001 1E (3/19)Preventive services under the Affordable Care Act (ACA)

6 Medication pharmacy managementMembership InformationMembership Members rights and responsibilitiesBlueCardOut of area program BlueCardBlueCard member identificationHow the BlueCard program worksContiguous areasExclusionsUtilization review (UR)BlueCard program claims submissionBlueCard billing and reimbursementBlueCard reimbursementBlueCard and health care exchangesThe National Account Service Company (NASCO)NASCO member identificationNASCO claim submissionMember Identification Card Quick Reference GuideFront of cardBack of cardProduct informationOut of area coverage (BlueCard) CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc.

7 And Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross and Blue Shield Names and Symbols are registered service marks of the Blue Cross and Blue Shield Association.

8 Provider Quick Reference GuideProducts / ID Card PrefixesProvider Service Phone #Where to Send ClaimsWhere to Send CorrespondenceBlueChoice XIK, XIR, XIB, QXG, QXA, XIE, JHZ, XWZ, XIG, QXKBluePreferred XIL, XWV, JHJ, XII, JHI, XIQ, QXM, XIY, XIUH ealthyBlue JHG, QXF, JHA, JHC, QXB, QXE, XIF, JHD, JHE, QXD, JHH, QXI, QXL, QXU, QXR, QXS, QXT, QXC, QXHI ndemnity XIJ, XWY800 842 5975 Mail Administrator Box 14116 Lexington, KY 40512 Mail Administrator Box 14114 Lexington, KY 40512 The National Account Service Company (NASCO)All prefixes are unique. CareFirst NASCO IDs begin with an 81 or 228 7268 Mail Administrator Box 14115 Lexington, KY 40512 Mail Administrator Box 14114 Lexington, KY 40512 Federal Employee Program (FEP)

9 R prefixDC/Metropolitan Area 202 488 4900MD 800 854 5256DC/Metropolitan Area Mail Administrator Box 14113 Lexington, KY 40512MD Mail Administrator Box 14113 Lexington, KY 40512DC/Metropolitan Area Mail Administrator Box 14112 Lexington, KY 40512MD Mail Administrator Box 14111 Lexington, KY 40512 BlueCardPrefixes are uniqueEligibility 800 676 2583 Out of area claims 877 228 7268 Send claims to your local plan: Mail Administrator Box 14116 Lexington, KY 40512 Mail Administrator Box 14114 Lexington, KY 40512 ResourcesContact Information and Phone #Link to WebsiteGeneral AssistanceCareFirst Help Desk: 877 526 8390 Behavioral HealthCareFirst: 800 245 7013 CredentialingProfessionalMail Administrator Box 14763 Lexington, KY 40512 Phone: 877 269 9593 or 410 872 3500 Fax: 410 872 4107 InstitutionalCareFirst BlueCross BlueShield 10455 Mill Run Circle Mail Stop CG 51 Owings Mills, MD 21117 Phone: 410 872 3526 Fax: 410 505 cert/Pre authMedical: 866 773 2884 CVS Pharmacy.

10 855 582 2038 CVS Specialty Pharmacy: 888 877 Caremark: 800 241 LabLabCorp:** 1 888 LabCorp (522 2677)Quest Diagnostics: 866 697 8378 (available to PPO members only)**Note: BlueChoice members must use Quick Reference GuideResourceAreaContact Phone #Other Party LiabilityCareFirst (Small/Medium Group and Consumer Direct)866 285 2611 Large Group, Consumer Directed Healthcare (CDH), Administrative Services Only (ASO)NASCO (Large Groups, CDH, ASO/self insured)877 228 7268 Workers Compensation/Subrogation443 471 5589 or 443 471 5585 FEP Workers Compensation/Subrogation800 854 5256 FEP Coordination of Benefits (COB)