Indemnity > PROVIDER MANUAL An indemnity information resource for

Transcription

Indemnity
PROVIDER MANUAL
An indemnity information resource for
our Provider community.
>
Contents
Welcome............................................................3
Administrative Functions.................................14
Important Phone Numbers and Addresses........4
Inquiry Process........................................................... 14
Claims Submissions.................................................... 14
Claims Overpayment............................................. 14
Timely Filing of Claims......................................... 14
Paper Claims Submission...................................... 15
Electronic Claim Submission................................ 15
Effective Follow-Up on Outstanding CareFirst
BlueCross BlueShield Indemnity Claims.................. 15
Step-By-Step Instructions for Effective
Follow-Up.............................................................. 15
Other Party Liability................................................... 16
Coordination of Benefits (COB).......................... 16
Subrogation........................................................... 17
Personal Injury Protection (PIP).......................... 17
Workers’ Compensation........................................ 17
Clinical Appeal Process.............................................. 17
Clinical Appeals and Analysis Unit....................... 17
Clinical Appeals Checklist..................................... 17
Expedited or Emergency Appeals Process................. 18
Appeal (or Grievance) Resolution............................. 18
Administrative or Technical Appeals......................... 18
Carefirst.com Resources........................................ 18
HIPAA Compliant Codes........................................... 18
In-Office Injectable Drugs Standard
Reimbursement Methodology................................... 19
Participating Provider Agreement (PAR).................. 19
Eligibility................................................................ 19
Physician Assistants............................................... 19
Reimbursement Allowances.................................. 19
Preferred Provider Agreements (PPN)...................... 20
Eligibility................................................................ 20
Reimbursement..................................................... 20
Collection of Retroactively Denied Claims............... 20
Changes in Provider Information.............................. 20
Termination of Agreement......................................... 20
Membership and Product Information...............8
Membership Identification Cards................................ 8
Traditional Products..................................................... 9
Preferred Provider Products........................................ 9
PPN.......................................................................... 9
PPO.......................................................................... 9
Medicare Supplemental Products................................ 9
TEFRA...................................................................... 9
Network Claims Product............................................ 10
Patient information............................................... 10
Claims Submission Process........................................ 10
Maryland Point of Service.......................................... 10
Primary Care Provider.......................................... 10
Specialist/Referral.................................................. 10
Direct Access.......................................................... 11
Claims/Benefits...................................................... 11
BlueCard® Program............................................... 11
Where to Direct Inquiries..................................... 12
Policy Statements............................................13
Care Management...................................................... 13
Mandatory Second Surgical Opinion (MSSOP) .13
Utilization Control Program (UCP)/Utilization
Control Program Plus (UCP+) ............................ 13
Coordinated Home Care and Home
Hospice Care ......................................................... 13
Individual Case Management (ICM) .................. 13
Outpatient Pre-Treatment Authorization Plan
(OPAP) .................................................................. 13
Magellan Health Services ..................................... 13
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indemnity INFORMATION PROVIDER MANUAL
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Welcome
Welcome to CareFirst BlueCross BlueShield (CareFirst)
and CareFirst BlueChoice, Inc. (CareFirst BlueChoice).
Your participation in one or all of our networks means
that you have access to thousands of local and national
employers and their employees. Our members have access
to state-of-the-art facilities, some of the best physician and
provider care in the country and medically proven advanced
technology.
This manual provides the information you need to service
CareFirst BlueCross BlueShield Indemnity members and
to do business with us.
If you have questions, please call Provider Services.
Visit www.carefirst.com/providers and click on Phone
Numbers and Claim Addresses to obtain the correct
phone number.
Note: For ease of communication, all references to
“CareFirst” will refer to both CareFirst BlueCross
BlueShield and CareFirst BlueChoice, Inc., unless
specified otherwise.
Per the terms of the Participating Agreement, all providers are
required to adhere to the policies and procedures contained in
this manual, as applicable to each type of provider.
Specific requirements of a member’s health benefits are
varied and may differ from and supersede the general
procedures outlined in this manual.
If we make any procedural changes in our ongoing
efforts to improve our service to you, we will update the
information in this manual and notify you via BlueLink,
our administrative newsletter.
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Important Phone Numbers and Addresses
Provider Services
Maryland Indemnity XW Prefix and
BlueCard® Claims
Mental Health for Level III and
Key Groups only
NCA Indemnity – XIA, XIJ and XWY
Prefixes & BlueCard® Claims
CareFirst BlueChoice – XIC, XIK and
XWR Prefixes
BluePreferred – XIP, XIL and XWV
Prefixes
What Number to Call Where to Send Claims or Correspondence
410-581-3581
800-437-2332
Claims:
Mail Administrator
P.O. Box 14115
Lexington, Ky 40512-4115
410-581-3581
Claims:
Mail Administrator
P.O. Box 14117
202-479-6560
800-842-5975
Claims:
Mail Administrator
P.O. Box 14116
Correspondence:
Mail Administrator
P.O. Box 14114
202-479-6560
800-842-5975
Claims:
Mail Administrator
P.O. Box 14116
Correspondence:
Mail Administrator
P.O. Box 14114
202-479-6560
800-842-5975
Claims:
Mail Administrator
P.O. Box 14116
Correspondence:
Mail Administrator
P.O. Box 14114
202-479-6560
800-842-5975
Claims:
Mail Administrator
P.O. Box 14116
Correspondence:
Mail Administrator
P.O. Box 14114
202-479-6560
800-842-5975
Claims:
Mail Administrator
P.O. Box 14116
Correspondence:
Mail Administrator
P.O. Box 14114
202-479-6560
800-842-5975
Claims:
Mail Administrator
P.O. Box 14116
Correspondence:
Mail Administrator
P.O. Box 14114
BlueChoice Advantage – XIR Prefix
BluePrecision – Blue Precision logo
on ID Card
Maryland Hospital Insurance Plan
(MHIP) – MHIP logo on ID Card
Dental HMO (The Dental Network)
Indicator – DH
Use 4 digit TDN site number
Discount Dental
Indicator – CareFirst BlueChoice
logo on ID Card with no dental
indicator
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410-847-9060
888-833-8464
Correspondence:
Mail Administrator
P.O. Box 14114
Claims:
Mail Administrator
P.O. Box 14118
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Important Phone Numbers and Addresses (continued)
State of Md Provider Services
State of Maryland – POS and PPO
877-228-7268
State of Maryland – HMO
877-228-7268
Claims & Correspondence:
CareFirst BlueCross
Mail Administrator
BlueShield
P.O. Box 14115
P.O. Box 9885
Baltimore, Md 21284-9885
Claims:
Mail Administrator
P.O. Box 14116
Correspondence & Appeals:
CareFirst BlueChoice
Mailstop RR230
Owings Mills, Md 21117-4208
or
CareFirst BlueChoice
P.O. Box 804
NASCO Provider Services
(NASCO - National Accounts
Service & Claims Operations)
Northrop Grumman – NRG Prefix
Northrop Grumman – ESS or NGC
Prefix
877-228-7268
800-972-8088
Claims:
Mail Administrator
P.O. Box 14115
Correspondence:
Mail Administrator
P.O. Box 14114
800-516-1269
Claims:
Mail Administrator
P.O. Box 14115
Correspondence:
Mail Administrator
P.O. Box 14114
877-228-7268
Claims:
Mail Administrator
P.O. Box 14115
Correspondence:
Mail Administrator
P.O. Box 14114
All other NASCO Accounts
FEP Provider Services
(FEP – Federal Employee
Program)
Federal Employee Program – R Prefix
Professional & Institutional Providers
in Montgomery & Prince George’s
counties, Washington, D.C. &
Northern Virginia (east of Rte. 123*)
All other Md FEP Providers
202-488-4900
Professional &
Institutional Inquiries:
410-581-3568
800-854-5256
Claims:
Mail Administrator
P.O. Box 14113
Correspondence:
Mail Administrator
P.O. Box 14112
Claims:
Mail Administrator
P.O. Box 14113
Correspondence:
Mail Administrator
P.O. Box 14111
*For Providers west of Rte. 123, send all claims and correspondence to local plan.
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Provider Contacts
BlueCard®
BlueCard® Eligibility
Provider Information and
Credentialing
800-676-BLUE
(2583)
410-872-3500
877-269-9593
Fax 410-872-4107
866-452-2304
Provider Relations and
Professional Contracting
410-872-3500
877-269-9593
Fax 410-505-6900
866-452-2306
Institutional and Vendor Contracting
410-872-3500
877-269-9593
Fax
410-872-4106
866-452-2305
Care Management
866-PRE-AUTH
(733-2884)
Fax
410-720-3058
Authorization
Claims:
Mail Administrator
P.O. Box 14115
Correspondence:
Mail Administrator
P.O. Box 14115
Correspondence:
CareFirst BlueCross BlueShield
10455 Mill Run Circle
P.O. Box 825
Mailstop CG-41
Correspondence:
P.O. Box 825
Mailstop CG-52
Correspondence:
P.O. Box 825
Mailstop CG-51
Correspondence:
Mail Administrator
P.O. Box 14114
866-PRE-AUTH
(733-2884) - Option 1
Fax 410-761-7661
Provider Seminar Registration
6
877-269-2219
Register online
www.carefirst.com > Providers and Physicians >
Register for a seminar
> >
Automated Voice Response Units
What Number to Call
BlueLine
410-581-3535
800-248-8410
Maryland Region — Authorizations, Eligibility and Claim and Benefit Inquiry for PPO, MPOS,
PPN and Md Indemnity
410-581-3535 800-248-8410
FirstLine
202-479-6560
800-842-5975
NCA Region — Eligibility, Claim and Benefit Inquiry for CareFirst BlueChoice, BluePreferred
and NCA Indemnity
202-479-6560
800-842-5975
Maryland Point of Service (MPOS) Referral Line
Vendor Contacts
Argus — Pharmacy benefits manager
Fax for referrals:
410-998-5741
What Number to Call
Prior authorization
requests:
800-314-2872
Fax 800-315-4025
Emdeon — Enrollment for electronic claims submission
866-369-8805
Icore Healthcare — Supplier of injectable drugs
866-522-2470
Laboratory Corporation of America (LABCORP) — Provides laboratory services for CareFirst
BlueChoice members
800-322-3629
Magellan Behavioral Health — Mental Health and Substance Abuse services
800-245-7013
Allscripts (Payerpath) — Enrollment for electronic claims submission
877-623-5706
ext. 1 - new clients
ext. 2 - existing clients
Direct number for Md.
providers: Travis Bacile
804-327-5085
RealMed — Enrollment for electronic claims submission
877-927-8000 ext. 1201
RelayHealth — Enrollment for electronic claims submission
800-527-8133 - Option 2
Walgreens Specialty Pharmacy (formerly McKession Specialty) — Supplier of injectable drugs
7
888-456-7274
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Membership and Product Information
Membership Identification Cards
Maryland Point of Service (MPOS)
Member Name
JOHN DOE
Member ID
XWM999999999
MARYLAND POINT OF SERVICE
PCP
John Smith, MD
BCBS Plan 190/690
Member Name
JOHN DOE
Member ID
XWV999999999
Group GG99
Eff Date 09/01/07
Coverage Type FAM
Plan Benefits
Group
0000000-0000
MPOS PR/SP 10/15
B E F $35 OP
VISION 3110 (Bin #011834 PCN #0300-0000)
BCBS Plan 080/580
Member Name
JOHN DOE
Member ID
XWG999999999
Group 1900000-OA00
Eff Date 01/01/08
Coverage Type
BCBS Plan 190/690
Plan Benefits
BC-365 BS-C DIAG4 MM ND P907
CITY BALTO/BFG
Maryland PPO/PPN
Member Name
JOHN DOE
Member ID
XWM999999999
Group 1900000-OA00
Eff Date 01/01/08
Coverage Type
P10 S20 ER25
DC Indemnity Traditional
Maryland Indemnity
8
DC Indemnity
Member Name
JOHN DOE
Member ID
XIJ999999999
PCP
Dr. Smith
Group
0HM0
BCBS Plan 080/580
Copay
P30 S40 DO ER100
National
BCBS Plan 190/690
Plan Benefits
P10 S20 ER25
Member Name
JOHN DOE
Member ID
USB999 99 9999
NATIONAL ACCOUNT
Group
1900000-OA00
PPO 80% $25 OV COPAY
SPECIALIST $35 OV COPAY
Eff Date 02/01/09
BCBS Plan 690/190
Coverage H&W
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Membership and Product Information (continued)
Federal Employee Program (FEP) – Standard Option
Government-Wide
Service Benefit Plan
Member Name
JOHN DOE
Member ID
R30048852
www.fepblue.org
Enrollment Code 105
Effective Date 01/01/2008
RxBIN RxPCN RxGrp Government-Wide
Service Benefit Plan
PPO
610415
PCS
65006500
Traditional Products
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:
n
Inpatient medical care
n
Surgical coverage
n
iagnostic services, as part of the diagnostic
D
endorsement
Types of benefits provided under Major Medical include
but are not limited to:
n
Office visits
n
Outpatient mental health
n
Physical therapy
n
Durable medical equipment (DME)
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).
9
Federal Employee Program (FEP) – Basic Option
Member Name
JOHN DOE
Member ID
R30048852
www.fepblue.org
Enrollment Code 112
Effective Date 01/01/2008
RxBIN RxPCN RxGrp Basic
610415
PCS
65006500
PPN
A PPN is a provider-driven product. This means that in
addition to the terms of the participating agreement, the
provider agrees to:
n
nsure that all managed care provisions of the
E
contract are met
n
Direct care to other PPN providers
n
ontact CareFirst if an out-of-network referral
C
is medically indicated (contact the referral
unit)
PPO
A PPO is a subscriber driven product. This means that
the subscriber agrees to:
n
Stay within the Preferred Provider Network
n
dhere to the managed care provisions of the
A
contract
Medicare Supplemental Products
CareFirst offers a variety of Medicare supplemental
products to compliment Medicare benefits. These
products 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 because
claims are not automatically forwarded to Medicare.
Network Claims Product
CareFirst jointly administers the Network Claims
product with third-party administrators (TPAs), selfinsured 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:
n
unique identification card bears the CareFirst
A
logo and the logo of the account or TPA
n
he prefix on the identification card begins
T
with ‘A’ followed by two numeric characters
n
Identification cards, Explanation of Benefits
(EOB), checks and vouchers will usually have
CareFirst’s and the account’s logo
Claims Submission Process
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 Provider
Internists, family practitioners, nurse practitioners and
pediatricians are eligible to contract with CareFirst to
become primary care providers 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.
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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 must be called in by the
PCP to Utilization Management (866-773-2884).
Direct Access
Generally certain services can be obtained without a
referral from the PCP and still be processed as in-network
services. These services 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:
n
Accidental care
n
Ambulance services
n
rtificial insemination/in-vitro fertilization
A
performed by PPN specialist
n
Hospice care
n
Human organ transplant
n
Emergency
n
ost outpatient diagnostic, machine and
M
laboratory testing and radiological service
(except MRI, CAT scan, Holter Monitor, and
interventional radiology)
Most psychiatric and substance abuse care should be
referred through Magellan Behavioral Health.
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 BlueCross BlueShield (BCBS)
members.
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.
Programs that are not affected by BlueCard® include:
Federal Employee Program, Medicare Secondary,
Maryland Dental Program, Vision Program, Pharmacy
Program and CareFirst’s HMOs including the HMO OptOut policies.
For benefit information, contact BlueLine, FirstLine,
CareFirst Direct or Provider Services (see “Important
Phone Numbers and Addresses”).
Providers located in Maryland should file claims based
on the following:
n
B/GYN services rendered by a PPN OB/GYN
O
or Nurse Midwife in his or her office
Some of your patients may have the Triple Choice product.
Level one of 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
11
a CareFirst participating provider or non-participating
provider and offers the lowest level of benefits.
n
rovider is participating with CareFirst’s
P
Maryland network only. Claims for all BCBS
subscribers, regardless of the BCBS plan that
they are enrolled through, must be submitted to
CareFirst.
> >
n
rovider is a preferred provider with CareFirst’s
P
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.
n
rovider is a preferred provider with CareFirst’s
P
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.
n
laims for CareFirst subscribers who hold a
C
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 of covered
services (deductibles, copayments, and coinsurance
amounts) 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). BlueCross BlueShield (BCBS) assigns
the first two positions (or letters) of the prefix and each
BCBS plan assigns the third. Most plans take advantage
of the ability to assign the third letter and use it to assist
with claims direction and contract identification.
12
CareFirst’s Maryland membership numbers begin with
the letters XW, CareFirst of DCs prefixes begin with 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
Electronic Data Interchange (EDI) vendor.
Where to Direct Inquiries
n Benefits and eligibility can be verified by contacting
the plan through which the patient is enrolled. To
do this, call toll free 800-676-2583 and you will
be directed to the appropriate BCBS plan. It is
important to obtain the 3-letter prefix from the
subscriber’s ID card prior to using this number.
n
laim status inquiries can be directed to
C
CareFirst. You can contact:
n
BlueLine: 410-581-3535 or 800-248-8410
n
FirstLine: 202-479-6560 or 800-842-5975
n
CareFirst Direct
n
P
rovider Services
202-479-6560 or 800-842-5975.
> >
Policy Statements
Care Management
Mandatory Second Surgical Opinion (MSSOP)
MSSOP is aimed at containing costs by reducing
unnecessary diagnostic and surgical procedures. It also
provides reassurance to patients having elective surgery
by either confirming the need for the surgery or advising
them of other forms of treatment. Some employer groups
elect Voluntary Second Surgical Opinion (VSSOP),
while others choose MSSOP for certain procedures.
If a subscriber’s contract requires MSSOP, a penalty is
applied if the VSSOP is not obtained. A practitioner who
is qualified to perform the surgery must perform the
VSSOP. The program applies to a specific list of diagnostic
and surgical procedures when they are performed on an
elective, non-emergency basis. The procedures on the
MSSOP list vary from account to account. To verify
procedures, check BlueLine.
Utilization Control Program (UCP)/Utilization
Control Program Plus (UCP+)
These are inpatient admission review programs designed
to contain hospital costs by reviewing admissions for
appropriateness and number of inpatient days. These
programs feature pre-admission review, admission review,
continued stay review, retrospective review, and discharge
planning. Notification of admissions to the CareFirst
Utilization Management department are required
(see Important Telephone Numbers).
Coordinated Home Care and Home Hospice Care
The Coordinated Home Care and Home Hospice Care
programs allow recovering and terminally ill patients to
stay at home and receive care in the most comfortable
and cost-effective setting. In order to qualify for program
benefits, the patient’s physician, hospital or home care
coordinator must submit a treatment plan to CareFirst. A
licensed home health agency or approved hospice facility
must render eligible services. Once approved, the home
health agency or hospice is responsible for coordinating
all services.
Individual Case Management (ICM)
ICM is a voluntary program available to those members
who have acute illnesses in a variety of specialty areas
including Aquired Immune Deficiency Syndrome (AIDS),
oncology, neonatology, pediatrics, high-risk obstetrics,
head injury, spinal cord injury as well as medicine and
surgery. Case management serves to coordinate and
support services that are aimed at assisting the member’s
attainment of short-term health objectives and long-term
goals.
Health care providers, patients, family members, employers
or anyone familiar with the case may refer candidates for
ICM (see Important Telephone Numbers).
Outpatient Pre-Treatment Authorization Plan (OPAP)
OPAP is a pre-treatment program that applies to
outpatient physical, speech and occupational therapy.
This program requires that CareFirst review and approve
the Initial Authorization Request Form prior to a given
visit (e.g., before the tenth visit) or prior to the first visit
depending on the subscriber’s contract.
The provider of care must complete a form that includes
the patient’s diagnosis and expected length of treatment.
The form will then be reviewed, and the provider and
subscriber will receive written notification of the decision.
Magellan Health Services
Magellan offers a full array of managed mental health,
substance abuse, and Employee Assistance Programs
(EAP) services, including utilization management,
PPO, HMO and point-of-service networks. Magellan
offers programs designed with a patient-advocacy focus
such as Care Management and enhanced utilization
management.
Care Management is Magellan’s network-based clinical
service program. It combines the best attributes of
utilization management with the clinical skills and
experience of a care management team that guides
referrals and serves as a patient’s advocate through the
entire episode of care.
Enhanced Utilization Management is a utilization review
process that works with each member’s provider to ensure
medically-necessary treatment in the most appropriate
setting.
13
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Administrative Functions
Inquiry Process
Providers should use CareFirst Direct or call Provider
Services regarding claim inquiries. Many inquiries can be
handled to the providers’ satisfaction in the appropriate
Provider Services area. If the inquiry cannot be satisfied
in the Service area, the provider will be instructed to
submit a written inquiry on a Provider Inquiry Resolution
Form (PIRF) to document the reason for the request
along with pertinent or supportive records, literature or
claims documentation to CareFirst Provider Services.*
To review the CareFirst claims adjudication and
payment policies, please refer to the Contents section
in this manual. These sections are especially helpful in
describing multiple claims billing guidelines, including
but not limited to Modifier Reimbursement Guidelines,
Bilateral Procedures Reimbursement Guidelines, Team
Surgery and Preventive Services.
*Please request reviews of processed claims within 6 months or 180 days
(whichever is greater) of the determination.
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, www.cms.gov.
Claims Overpayment
If a claims overpayment is discovered and you wish to
return the payment to CareFirst, please mail it to:
P.O. Box 791021
Baltimore, Md 21279
Please include the membership number, patient name,
claim number and the reason for the refund with your
check. The check should be made 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.
14
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.
Documentation is required for this process.
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.
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
computer 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 12, indicating the bill creation date.
> >
Administrative Functions (continued)
Paper Claims Submission
Paper claims are scanned and a digitized version of the
claim that is produced is 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:
n
n
n
n
n
n
n
n
n
n
n
n
lock 1a: Insured’s ID Number*
B
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)
Effective Follow-Up on Outstanding
CareFirst BlueCross BlueShield Indemnity
Claims
To follow-up on claims submitted over 30-days ago, you
can check BlueLine to determine the claim status.
Do not resubmit claims without checking BlueLine,
FirstLine or CareFirst Direct first. Submitting a duplicate
of a claim already in process will generate a rejection,
which 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:
n
n
n
ccess BlueLine, FirstLine, or CareFirst
A
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
*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 fit properly in the blocks
provided.
Electronic Claim Submission
Electronic claims submission is the automated filing
of claims utilizing a computer software package and
transmitting the claims electronically. See page 7 for a
list of electronic claims submission vendors.
15
> >
Large Volume of Unpaid Claims
n Please be sure that all vouchers and/or
remittance tapes have been posted
n Use BlueLine to verify receipt and status of
claims
n If you still have questions, please contact the
appropriate provider customer service unit for
assistance
n
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
n
Mail to the appropriate claims address
Medicare Supplemental/Complementary
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:
Other Party Liability
n
heck BlueLine, FirstLine, or CareFirst Direct
C
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
I f there is no record of the supplemental claim, please
follow these steps:
16
I f the claim has been pending for more than 30 days,
please contact the appropriate provider customer service
unit for assistance.
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. The Maryland 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.
17
Clinical Appeal Process
Clinical Appeals and Analysis Unit
The Clinical Appeals and Analysis Unit (CAU) is
responsible for review, preparation, reconciliation and
communication, reporting and analysis of clinical
appeals for CareFirst. The CAU is the primary contact
for appeals for internal and external auditing agencies.
Clinical Appeal Checklist
CAU reviews and responds to clinical appeals. CareFirst
has one internal level for the appeals process. Appeals
must be submitted within 180 calendar days or six (6)
months, whichever is longer, from the date the adverse
decision was received.
A letter describing the reason(s) for the appeal and the
clinical justification or rationale is required including the
following information, if possible:
n
Patient’s name and identification number
n
Provider number or tax identification number
n
dmission and discharge date, if applicable or
A
the date(s) of service
n
The treating physician’s name
n
The complete inpatient medical record
n
Relevant outpatient records
n
letter of medical necessity addressing specific
A
related clinical information. Supporting clinical
notes or medical records includes pertinent lab
reports, x-rays, treatment plans and progress
notes.
n
If the appeal includes a request for review
of ancillary services, the letter of medical
necessity should specifically state the medical
necessity of the ancillary services on the denied
days.
n
I f the appeal involves inpatient days, a licensed
physician who is a member of the hospital’s
staff or a nurse working in conjunction with
the physician should write the letter of medical
necessity.
n
I f a nurse writes the letter of medical necessity,
it should indicate the physician(s) involvement
in the appeal
> >
Expedited or Emergency Appeals Process
Administrative or Technical Appeals
You may request an expedited or emergency appeal after
an adverse decision for preauthorization of a service,
admission, continued length of stay or awaiting service
or treatment. An expedited or emergency appeal is
defined as one where a delay in receiving the health care
service could seriously jeopardize the life or health of
the member or the member’s ability to function or cause
the member to be a danger to self or others. Expedited
appeals may be faxed to 410-528-7053.
CAU does not review or respond to administrative or
technical appeals. For direct questions about claims that
deny because of enrollment, co-pay/deductible, lack of
preauthorization and claims payment should contact
Provider Services at 800-842-5975 or 202-479-6560. Any
hospital representative may submit these appeals.
An expedited appeal may include, but is not limited
to, a physician to physician or peer to peer review,
when an adverse decision has been rendered regarding
a concurrent inpatient length of stay. An emergency
includes a service not yet provided (i.e., a prospective
service that is not yet a claim.) We will answer an
expedited or emergency appeal within 24 hours from
the date the appeal is received. The grievance will be
reviewed by a physician not involved in the initial denial
determination. There is a full and fair review process for
all grievance decisions.
Appeal (or Grievance) Resolution
n
hen a claim is denied for “no authorization
W
obtained,” this indicates there is not a
contractually required pre-certification on file.
n
o submit a payment dispute for “no
T
authorization,” give a specific reason why precertification could not be obtained and include
the complete medical record
n
e will return requests for reconsideration
W
without the above information citing “denial
of payment upheld,” until the request is
submitted with the information needed to
complete the review.
Carefirst.com Resources
The following information is available on our Web site:
Once the internal appeal process is complete, you will
receive a written decision that will include the following
information:
n
areFirst Drug Information includes information
C
about prior authorization requirements, quantity
limits and the CareFirst formulary
n
areFirst Medical Policy Manual has the most
C
up-to-date medical policy information and
guidelines
n
laims Adjudication and Associated
C
Reimbursement Policy information, including
details on Billing and Reimbursement
Guidelines
n
The specific reason for the appeal decision.
n
reference to the specific benefit provision,
A
guideline protocol or other criteria on which
the decision was based.
18
n
n
statement regarding the availability of all
A
documents, records or other information
relevant to the appeal decision, free of charge
including copies of the benefit provision,
guideline, protocol or other similar criterion
on which the appeal decision was based.
otification that the diagnosis code and its
N
corresponding meaning, and the treatment
code and its corresponding meaning will be
provided free of charge upon request.
n
ontact information regarding a State
C
consumer assistance program.
n
I nformation regarding the next level of appeal,
as appropriate.
Written appeals should be mailed to:
Mail Administrator
P.O. Box 14114
Lexington, KY 40512-4114
HIPAA Compliant Codes
To comply with the requirements of the Health Insurance
Portability and Accountability Act (HIPAA), CareFirst
and CareFirst BlueChoice will add the HIPAA-compliant
codes and corresponding reimbursement rates to your
fee schedule when they are released from AMA or CMS.
These updates are made on a quarterly basis through the
calendar year.
> >
In-Office Injectable Drugs Standard
Reimbursement Methodology
submitted under the supervising physician’s name and
provider number.
In-Office Injectable drugs are reimbursed at a percentage
of the Average Sales Price (ASP). In-Office Injectable
drugs without an ASP are reimbursed at a percentage
of the lowest Average Wholesale Price (AWP). The ASP
is calculated by the Centers for Medicare & Medicaid
Services (CMS) and available at CMS.gov. The AWP is
based on the most cost effective product and package size
as referenced in Thomson’s Red Book.
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
prov iders 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.
Reimbursement for all in-office injectable drugs is
updated quarterly on the first of February, May, August
and November. The rates are in effect for the entire
quarter but are subject to change each quarter. P4
Oncology and P4 Rheumatology fee schedules are not
included in this reimbursement methodology.
Participating Provider Agreement (PAR)
The major terms of the PAR agreement require that the
provider:
n
n
n
ile claims on behalf of the member
F
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
Phone Numbers and Addresses”).
Physician Assistants
Covered services rendered by Physician Assistants (PA)
are eligible for reimbursement under the following
circumstances:
n
A is under the supervision of a physician as
P
required by local licensing agencies
n
Services rendered by the PA are submitted
under the supervising physician’s name and
provider number
CareFirst BlueChoice does not contract with Physician
Assistants. Physician Assistants’ services are to be
19
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.
articipating providers shall not charge, collect
P
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:
n
Submit all claims directly to CareFirst
n
ccept the Preferred Provider Allowed Benefit
A
as payment in full
n
ill CareFirst members only for deductibles,
B
copayment, coinsurance, and non-covered services
n
irect care of PPN patients to other PPN
D
providers
n
otify CareFirst if an out of network referral
N
is required
n
nsure that the managed care provisions of
E
the contract are met
Eligibility
Preferred providers must meet CareFirst’s credentialing
standards.
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.
20
Collection of Retroactively Denied Claims
A provider reimbursement may be offset against a
retroactively denied claim by an affiliated company of
CareFirst, Inc.
Changes in Provider Information
CareFirst health care providers who need to change their
provider information should use a Change in Provider
Information Form found on our website www.carefirst.
com/providers/forms. 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 to:
Provider Information and Credentialing
Mailstop CG-41
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,
prov iders must prov ide w ritten notif ication of
termination with 90 days notice.
> >
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
BOK5366-1N (7/12)
> >

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Indemnity > PROVIDER MANUAL An indemnity information resource for