CareFirst Indemnity Provider Manual · This manual provides the information you need to ......

IndemnityPROVIDER MANUAL

An indemnity information resource for our Provider community.

Contents

Welcome............................................................3

Important.Phone.Numbers.and.Addresses........4

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

Administrative.Functions.................................14 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

indemnity inFORmAtiOn PROVideR mAnUAL 2

http:Carefirst.com

Welcome

Welcome to CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice). Your par ticipation 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.

Specific requirements of a members health benefits are varied and may differ from and supersede the general procedures outlined in this manual.

If we ma ke a ny procedura l cha nges in ou r ongoi ng efforts to improve our service to you, we will update the information in this manual and notif y you via BlueLink, our administrative newsletter.

If you have quest ions, please c a l l Prov ider Ser v ices. Visit w w w.carefi rst.com /prov iders and click on Phone Numbers a nd Claim Addresses to obtain t he correct phone number.

Note : For ea se of com mu n ic at ion, a l l references to C a reFi rst w i l l refer to bot h C a reFi rst Blue Cros s Blue Sh ield a nd C a reFi rst Blue C hoice, I nc ., u n le ss 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.

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https://provider.carefirst.com/wps/portal/Provider/ProviderHome

Important.Phone.Numbers.and.Addresses

Provider Services What Number to Call Where to Send Claims or Correspondence Maryland Indemnity XW Prefix and Claims: Correspondence: BlueCard Claims 410-581-3581 mail Administrator mail Administrator

800-437-2332 P.O. Box 14115 P.O. Box 14114 Lexington, Ky 40512-4115 Lexington, Ky 40512-4114

Mental Health for Level III and Claims: Key Groups only mail Administrator

410-581-3581 P.O. Box 14117 Lexington, Ky 40512-4117

NCA Indemnity XIA, XIJ and XWY Claims: Correspondence: Prefixes & BlueCard Claims 202-479-6560 mail Administrator mail Administrator


CareFirst BlueChoice XIC, XIK and Claims: Correspondence: XWR Prefixes 202-479-6560 mail Administrator mail Administrator


BluePreferred XIP, XIL and XWV Claims: Correspondence: Prefixes 202-479-6560 mail Administrator mail Administrator


BlueChoice Advantage XIR Prefix Claims: Correspondence: 202-479-6560 mail Administrator mail Administrator 800-842-5975 P.O. Box 14116 P.O. Box 14114

Lexington, Ky 40512-4116 Lexington, Ky 40512-4114

BluePrecision Blue Precision logo Claims: Correspondence: on ID Card 202-479-6560 mail Administrator mail Administrator


Maryland Hospital Insurance Plan Claims: Correspondence: (MHIP) MHIP logo on ID Card 202-479-6560 mail Administrator mail Administrator


Dental HMO (The Dental Network) Claims: Indicator DH mail Administrator Use 4 digit TDN site number P.O. Box 14118

410-847-9060 Lexington, Ky 40512-4118 Discount Dental 888-833-8464 Indicator CareFirst BlueChoice logo on ID Card with no dental indicator


Important.Phone.Numbers.and.Addresses (continued)

State of Md Provider Services What Number to Call Where to Send Claims or Correspondence State of Maryland POS and PPO Claims & Correspondence:

mail Administrator CareFirst BlueCross 877-228-7268 P.O. Box 14115 BlueShield

Lexington, Ky 40512-4115 P.O. Box 9885 Baltimore, md 21284-9885

State of Maryland HMO Claims: Correspondence & Appeals: mail Administrator CareFirst BlueChoice P.O. Box 14116 mailstop RR230 Lexington, Ky 40512-4116 Owings mills, md 21117-4208

877-228-7268 or

CareFirst BlueChoice P.O. Box 804 Owings mills, md 21117-9998

NASCO Provider Services (NASCO - National Accounts What Number to Call Where to Send Claims or Correspondence Service & Claims Operations) Northrop Grumman NRG Prefix Claims: Correspondence:

877-228-7268 mail Administrator mail Administrator 800-972-8088 P.O. Box 14115 P.O. Box 14114


Northrop Grumman ESS or NGC Claims: Correspondence: Prefix mail Administrator mail Administrator


All other NASCO Accounts Claims: Correspondence: mail Administrator mail Administrator


FEP Provider Services (FEP Federal Employee Program)

What Number to Call Where to Send Claims or Correspondence

Federal Employee Program R Prefix

Professional & institutional Providers in montgomery & Prince Georges 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 Lexington, Ky 40512-4113

Correspondence: mail Administrator P.O. Box 14112 Lexington, Ky 40512-4112

Claims: mail Administrator P.O. Box 14113 Lexington, Ky 40512-4113

Correspondence: mail Administrator P.O. Box 14111 Lexington, Ky 40512-4111

*For Providers west of Rte. 123, send all claims and correspondence to local plan.



w w w.carefirst.com > Providers and Physicians > Register for a seminar

Provider Contacts What Number to Call Where to Send Claims or Correspondence BlueCard Claims: Correspondence:

800-676-BLUe mail Administrator mail Administrator BlueCard eligibility (2583) P.O. Box 14115 P.O. Box 14115


Provider information and Correspondence: 410-872-3500 Credentialing CareFirst BlueCross BlueShield 877-269-9593

10455 mill Run Circle Fax P.O. Box 825

410-872-4107 mailstop CG-41 866-452-2304 Owings mills, md 21117-0825

Provider Relations and Correspondence: 410-872-3500 Professional Contracting CareFirst BlueCross BlueShield 877-269-9593

10455 mill Run Circle Fax P.O. Box 825

410-505-6900 mailstop CG-52 866-452-2306 Owings mills, md 21117-0825

institutional and Vendor Contracting Correspondence: 410-872-3500 CareFirst BlueCross BlueShield 877-269-9593 10455 mill Run Circle

Fax P.O. Box 825 410-872-4106 mailstop CG-51 866-452-2305 Owings mills, md 21117-0825

Care management 866-PRe-AUtH Correspondence: (733-2884) mail Administrator

P.O. Box 14114 Fax Lexington, Ky 40512-4114 410-720-3058

Authorization 866-PRe-AUtH (733-2884)-Option 1

Fax 410-761-7661

Provider Seminar Registration Register online 877-269-2219


http://www.carefirst.comhttp://www.carefirst.com/providers/html/ProvidersHome.htmlhttp://notesnet.carefirst.com/ecommerce/provseminarreg.nsf/frmprofessionalregistration?OpenForm


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 Ser vice (MPOS) Referral Line Fax for referrals: 410-998-5741

Vendor Contacts What Number to Call Argus Pharmacy benefits manager 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 888-456-7274


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Membership.and.Product.Information

Membership Identification Cards

Maryland Point of Service (MPOS) DC Indemnity

Maryland Indemnity DC Indemnity Traditional

MemberName JOHNDOE MemberID XWM999999999

GroupGG99 EffDate09/01/07 CoverageTypeFAM MPOS PR/SP 10/15

BEF $35 OP VISION 3110

MARYLANDPOINTOFSERVICE PCP JohnSmith,MD BCBSPlan190/690

PlanBenefits

MemberName JOHNDOE MemberID XWG999999999

Group1900000-OA00 EffDate01/01/08 CoverageType

BC-365BS-CDIAG4MM NDP907 CITYBALTO/BFG

BCBSPlan190/690PlanBenefits

MemberName JOHNDOE MemberID XWV999999999

Group 0000000-0000

(Bin#011834PCN#0300-0000) BCBSPlan080/580 P10S20ER25

MemberName JOHNDOE MemberID XIJ999999999

Group 0HM0

BCBSPlan080/580

Copay P30S40DOER100

PCP Dr.Smith

Maryland PPO/PPN National

MemberName JOHNDOE MemberID XWM999999999

Group1900000-OA00 EffDate01/01/08 CoverageType

P10S20ER25

BCBSPlan190/690PlanBenefits

MemberName JOHNDOE MemberID USB999999999

NATIONALACCOUNT

Group 1900000-OA00

EffDate02/01/09 BCBSPlan690/190

PPO80%$25OVCOPAY SPECIALIST$35OVCOPAY

CoverageH&W

Membership.and.Product.Information.(continued)

Federal Employee Program (FEP) Standard Option Federal Employee Program (FEP) Basic Option

MemberName JOHNDOE MemberID R30048852

EnrollmentCode 105 EffectiveDate 01/01/2008

RxBIN 610415 RxPCN PCS RxGrp 65006500

www.fepblue.org

Government-Wide ServiceBenefitPlan

PPO

MemberName JOHNDOE MemberID R30048852

EnrollmentCode 112 EffectiveDate 01/01/2008

RxBIN 610415 RxPCN PCS RxGrp 65006500

www.fepblue.org

Government-Wide ServiceBenefitPlan

Basic

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. Subs c r ib ers may c a r r y M ajor Med ic a l covera ge i n addition to Plan C.

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

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n

n

Inpatient medical care

Surgical coverage

Diagnostic services, as part of the diagnostic endorsement

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

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n

n

n

Office visits

Outpatient mental health

Physical therapy

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-net work prov ider, benefits w ill be provided, in most cases, but the member will be responsible for deduc t ible s a nd coi nsu ra nce. C a reFi r s t of fers t wo preferred provider products : Preferred Provider Network (PPN) and Preferred Provider Organization (PPO).

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

n

n

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 product. This means that the subscriber agrees to:

n

n

Stay within the Preferred Provider Network

Adhere to the managed care provisions of the contract

Medicare Supplemental Products Ca reFi rst of fers a va r iet y of Med ica re supplementa l pro duc t s to c ompl i me nt Me d ic a re benef it s . T he se products are offered through group contracts as well as directly to individual subscribers.

TEFRA The Tax Equity and Fiscal Responsibility Act (TEFR A) 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 DEFR A is an amendment to TEFR A which stipulates that spouses fall under TEFR A) age 65 and over of an active employee, may enroll in the same group coverage offered to younger


indemnity inFORmAtiOn PROVideR mAnUAL


employees and t heir spouses. In insta nces where t he employee or spouse ha s elec ted t he g roup coverage, Ca reFi rst is t he pr i ma r y c a r r ier to whom t he cla im should be submitted f irst, Medicare is the secondar y carrier. Af ter 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 C a reFi r s t joi nt ly ad m i n i s ters t he Ne t work C la i m s product with third-party administrators (TPAs), self-i nsu red employers, a nd hea lt h a nd wel fa re f u nd s . Because CareFirst shares administrative tasks with these entities, employers are able to access CareFirsts provider networks, design hea lth benef its, and share f inancia l 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

n

n

A unique identification card bears the CareFirst logo and the logo of the account or TPA

The prefix on the identification card begins with A followed by two numeric characters

Identification cards, Explanation of Benefits (EOB), checks and vouchers will usually have CareFirsts and the accounts logo

Claims Submission Process Providers should submit claims following the instructions that appear on the reverse side of the patients identification card. The patients alpha/numeric prefix and the CareFirst prov ider number must be submit ted on a ll claims to ensure timely processing.

Cla i ms ca n be submit ted elec t ron ica l ly or on paper, as identified in the CareFirst participating agreement. Participating prov iders ag ree to accept t he Ca reFirst 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 patients identification card.

Maryland Point of Service

Primary Care Provider Internists, family practitioners, nurse practitioners and pediatricians are eligible to contract with CareFirst to become primar y care prov iders under the Mar yla nd 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 a nd 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 members 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 specialists 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 Genera l ly cer tain ser v ices can be obtained w it hout a referral from the PCP and still be processed as in-network services. These ser vices are referred to as direct access ser v ices. Please keep in mind that benef its for these services would still need to be verified by the appropriate provider service area. They are:

n Accidental care

Ambulance services

Artificial insemination/in-v itro 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 radiolog y)

OB/GYN services rendered by a PPN OB/GYN or Nurse Midwife in his or her office

n

n

n

n

n

n

n

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

Claims/Benefits Claims may be submit ted electronica l ly or on paper. Paper claims are to be submitted to the normal CareFirst add re s s. Nat iona l ac c ou nt pape r c la i m s shou ld be submitted to the CareFirst NASCO address.

For benef it information, contact BlueLine, FirstLine, CareFirst Direct or Prov ider Ser v ices (see Important Phone Numbers and Addresses).

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

a CareFirst participating provider or non-participating provider and offers the lowest level of benefits.

BlueCard Program Ca reFi rst a long w it h t he Blue Cross A ssociat ion i n Chicago implemented the BlueCard Program. Providers who pa r t icipate w it h Ca reFirsts Mar yla nd prov ider network should accept all BlueCross BlueShield (BCBS) members.

Prog ra ms t hat are not af fected by BlueCard include : Fe d e r a l E mploy e e P ro g r a m , Me d ic a r e S e c ond a r y, Maryland Dental Program, Vision Program, Pharmacy Program and CareFirsts HMOs including the HMO Opt-Out policies.

Prov iders located in Mar yland should fi le claims based on the following :

n Provider is participating with CareFirsts Maryland network only. Claims for all BCBS subscribers, regardless of the BCBS plan that they are enrolled through, must be submitted to CareFirst.

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n Provider is a preferred provider with CareFirsts 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 Provider is a preferred provider with CareFirsts 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 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 of covered ser v ices (deduc t ibles, copay ment s, a nd coinsura nce amounts) based on CareFirsts 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 Secondar y, Ma r yland Denta l Program, and CareFirsts 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.

CareFirsts 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 pref ix appears on the claim form. The pref i x should be obtained from the subscribers 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 subscribers ID card prior to using this number.

n Claim status inquiries can be directed to 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 Provider Services 202-479-6560 or 800-842-5975.

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https://provider.carefirst.com/wps/portal/Provider


Policy.Statements

Care Management

Mandatory Second Surgical Opinion (MSSOP) MS S OP i s a i me d at c ont a i n i ng c o s t s b y re duc i ng 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 elec t Volu nta r y Second Surg ic a l Opi n ion (VSSOP), whi le ot hers choose MSSOP for cer ta i n procedu res. If a subscribers contract requires MSSOP, a penalty is applied if the VSSOP is not obtained. A practitioner who is qua lif ied to perform t he surger y 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 var y f rom account to account. To verif y procedures, check BlueLine.

Utilization Control Program (UCP)/Utilization Control Program Plus (UCP+) These are inpatient admission review programs designed to contain hospita l costs by rev iew ing ad missions for appropriateness and number of inpat ient days. These programs feature pre-admission review, admission review, continued stay review, retrospective review, and discharge planning. Notificat ion of admissions to t he CareFirst Ut i l i z at ion Ma n agement depa r t ment a re re qu i re d (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 qualif y for program benefits, the patients 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 specialt y areas including Aquired Immune Deficiency Syndrome (AIDS), oncolog y, neonatolog y, pediatrics, high-risk obstetrics, head injur y, spinal cord injury as well as medicine and surger y. Case management ser ves to coordinate a nd support services that are aimed at assisting the members 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) OPA P i s a pre -t reat ment prog ra m t h at appl ie s 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 subscribers contract.

The provider of care must complete a form that includes the patients 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, substa nce abuse, and Employee Assistance Progra ms (E A P) s er v ice s , i nclud i ng ut i l i z at ion m a nagement, PPO, HMO and point-of-ser v ice net works. Magel lan offers programs designed with a patient-advocacy focus such a s Ca re Ma nagement a nd en ha nced ut i l i z at ion management.

Care Management is Magellans network-based clinical ser v ice prog ra m. It combi nes t he best at t r ibutes of ut i l i z at ion ma nagement w it h t he cl i nica l sk i l ls a nd ex per ience of a ca re ma nagement tea m t hat g u ides referrals and serves as a patients advocate through the entire episode of care.

Enhanced Utilization Management is a utilization review process that works with each members provider to ensure medically-necessary treatment in the most appropriate setting.

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ndei mnity inFORmAtiOn PROVideR mAnUAL

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 t he Ser v ice area, t he prov ider w ill be instructed to submit a written inquiry on a Provider Inquiry Resolution Form (PIR F) to document the reason for t he request along with pertinent or supportive records, literature or claims documentation to CareFirst Provider Services.*

To re v ie w t h e C a reF i r s t c l a i m s adjud ic at ion a nd 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 Mar yland law addressing uniform claim form submission, al l hea lth care practitioners licensed or certified under the Health Occupation Article, Annotated Codes of Maryland must use the Centers for Medicare and Medica id Ser v ices (CMS) 150 0 as t he 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, ww w.cms.gov.

Claims Overpayment If a claims overpayment is discovered and you wish to return the payment to CareFirst, please mail it to:

CareFirst BlueCross BlueShield P.O. Box 791021 Ba ltimore, 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.

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 t hat the claim was submitted to CareFirst w ithin t he 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 af ter six months will not be accepted and the charges may not be bil led 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 cla ims : A screen print f rom t he prov iders 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.

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https://provider.carefirst.com/wps/portal/Providerwww.cms.gov


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 a nd your cla im may be returned to you. Please ma ke sure to change typewriter ribbons or printer cartridges regularly so that the print is dark.

Incomplete claims create unnecessar y 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

Block 1a: Insureds ID Number*

Block 2: Patients Name

Block 3: Patients 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)

*The 3-digit prefix must be included if present on the subscribers

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 origina l (red /white) C M S 15 0 0 f o r m . C l a i m s t h a t a r e s u b m i t t e d on photocopies or forms other than an original CMS 1500 require manual input, which may result in processing delay. A l l information must fit properly in the blocks provided.

Electronic Claim Submission Electronic cla ims submission is t he automated f iling of claims uti lizing a computer sof t ware package and transmitting the claims electronically. See page 7 for a list of electronic claims submission vendors.

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 w ithout check ing BlueLine, FirstLine or CareFirst Direct first. Submitting a duplicate of a claim already in process w ill generate a rejection, which will cause a backlog of unnecessar y claims to be processed.

Step-By-Step Instructions for Effective Follow-Up

Claim Status T he most ef fect ive way to accompl ish fol low-up on submitted claims is to:

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Access BlueLine, FirstLine, or CareFirst 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

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Large Volume of Unpaid Claims n Please be sure that all vouchers and /or

remittance tapes have been posted

n Use BlueLine to verif y receipt and status of claims

n If you still have questions, please contact the appropriate provider customer service unit for assistance

Medicare Supplemental/Complementary Please allow approximately 30 days for the claim to be processed through the spin-off system af ter you receive the Medicare Remittance Notice. If processing f rom CareFirst does not occur in 30 days, please follow these steps :

n Check BlueLine, FirstLine, or CareFirst Direct to verify that the claim has not been received by CareFirst. You do not need to wait 30 days from Medicares processing date to check BlueLine, FirstLine, or CareFirst Direct. You may check any time after the receipt of a Medicare Remittance Notice

If there is no record of the supplemental claim, please follow these steps:

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

If the claim has been pending for more than 30 days, please contact the appropriate provider customer service unit for assistance.

Other Party Liability 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 a lso eligible for healt h insurance benef its t hrough another insurance company or Medicare.

If Ca reFi rst is t he pr i ma r y c a r rier, f u l l benef its a re pr ov ide d a s s t ipu l at e d i n t he me m b e rs c ont r a c t . 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.

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Group contracts may stipulate different methods of benefits coordination. However, generally CareFirsts 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 CareFirsts allowed benefit, except when Medicare is primary.

Claims for secondar y benefits must be accompanied by the explanation of benefits (EOB) from the primar y 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 insura nce prov ision t hat covers medica l ex penses a nd lost wages experienced by the i n su re d or pa s s engers a s a re su lt of a n automobi le accident. T he mi n i mu m coverage is $ 2,50 0. W hi le Ma r yla nd law wa s a mended i n 1989 to requi re t his 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 a nd of f icers of closed cor porations from mandator y 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 t he denia l from the workers compensation carrier to the claim.

Clinical Appeal Process

Clinical Appeals and Analysis Unit T he Cl i n ic a l Appe a l s a nd A na ly si s Un it (C AU) i s responsible for review, preparation, reconciliation and com mu n ic at ion, rep or t i ng a nd a na l y si s of c l i n ic a l appeals for CareFirst. The CAU is the primar y 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:

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Patients name and identification number

Provider number or tax identification number

Admission and discharge date, if applicable or the date(s) of service

The treating physicians name

The complete inpatient medical record

Relevant outpatient records

A letter of medical necessity addressing specific related clinical information. Supporting clinical notes or medical records includes pertinent lab reports, x-rays, treatment plans and progress notes.

If the appeal includes a request for review of ancillary ser vices, the letter of medical necessity should specifically state the medical necessity of the ancillary services on the denied days.

If the appeal involves inpatient days, a licensed physician who is a member of the hospitals staff or a nurse working in conjunction with the physician should write the letter of medical necessity.

If a nurse writes the letter of medical necessity, it should indicate the physician(s) involvement in the appeal

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Expedited or Emergency Appeals Process You may request an expedited or emergency appeal after an adverse decision for preaut horization of a ser v ice, admission, continued length of stay or awaiting service or t reat ment. A n ex ped ited or emergenc y appea l is defined as one where a delay in receiving the health care ser vice could seriously jeopardize the life or health of the member or the members ability to function or cause the member to be a danger to self or others. Expedited appeals may be faxed to 410-528-7053.

A n expedited appea l may include, but is not limited to, a physicia n to physicia n or peer to peer rev iew, when an adverse decision has been rendered regarding a concurrent inpatient leng th of stay. An emergency includes a ser vice not yet provided (i.e., a prospective ser v ice t hat is not yet a cla i m.) We w i l l a nswer a n ex pedited or emergency appeal w it hin 24 hours f rom t he date t he appeal is received. The grievance w il l 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 Once the internal appeal process is complete, you will receive a written decision that will include the following information:

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The specific reason for the appeal decision.

A reference to the specific benefit provision,

guideline protocol or other criteria on which

the decision was based.

A statement regarding the availability of all

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.

Notification that the diagnosis code and its

corresponding meaning, and the treatment code and its corresponding meaning will be

provided free of charge upon request.

Contact information regarding a State consumer assistance program.

Information regarding the next level of appeal,

as appropriate.

Administrative or Technical Appeals 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 cla ims pay ment should contact Provider Services at 800-842-5975 or 202-479-6560. Any hospital representative may submit these appeals.

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When a claim is denied for no authorization obtained, this indicates there is not a contractually required pre-certification on fi le.

To submit a payment dispute for no authorization, give a specific reason why pre-certification could not be obtained and include the complete medical record

We will return requests for reconsideration 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:

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CareFirst Drug Information includes information about prior authorization requirements, quantity limits and the CareFirst formulary

CareFirst Medical Policy Manual has the most up-to-date medical policy information and guidelines

Claims Adjudication and Associated Reimbursement Policy information, including details on Billing and Reimbursement Guidelines

Written appeals should be mailed to: M a i l Ad m i n i s t r ator P.O. B ox 14114 L e x i n g to n , K Y 4 0 512 -4114

HIPAA Compliant Codes To comply with the requirements of the Health Insurance Portability and Accountability Act (HIPA A), 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.

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In-Office Injectable Drugs Standard Reimbursement Methodology In-Office Injectable drugs are reimbursed at a percentage of the Average Sa les Price (ASP). In-Of f ice Injectable drugs without an ASP are reimbursed at a percentage of the lowest Average Wholesale Price (AWP). The ASP is ca lcu lated 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 Thomsons Red Book.

Rei mbu rsement for a l l i n-of f ice i njec table d r ugs is updated quarterly on the first of February, May, August a nd November. The rates are in ef fect for the entire qu a r ter but a re subje c t to cha nge e ach qu a r ter. P4 Oncolog y and P4 R heumatolog y fee schedules are not included in this reimbursement methodology.

Participating Provider Agreement (PAR) The major terms of the PAR agreement require that the provider:

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File claims on behalf of the member

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 hea lth care professionals a re 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) a re el ig ible for rei mbu rsement u nder t he fol low i ng circumstances:

n PA is under the supervision of a physician as required by local licensing agencies

n Services rendered by the PA are submitted under the supervising physicians name and provider number

CareFirst BlueChoice does not contract with Physician A s si s t a nt s . Phy sic ia n A s si s t a nt s ser v ic e s a re to b e

submitted under the supervising physicians name and provider number.

Reimbursement Allowances Pa r t icipat i ng prov iders ag ree to accept t he A l lowed Benefit or AB as determined by CareFirst. This means that participating providers cannot bill the subscriber/ pat ient for t he d if ference bet ween t heir cha rge a nd the allowed benefit for covered ser vices. Participating p r ov i d e r s m a y b i l l s u bs c r i b e r s f o r d e d u c t i b l e s , 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.

Providers cannot require the payment of charges above and beyond coinsurance, copayments and deductibles. To help you evaluate your offices current practices, our policy is below.

Participating providers shall not charge, collect 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 of fice 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 ser vices not covered under the members 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 whe n the records are being processed for the subscriber or member directly.

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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) Pa r t icipat i ng prov iders a re a lso elig ible to become Preferred Providers. Major provisions of the Preferred Provider Agreement include :

n Submit all claims directly to CareFirst

Accept the Preferred Provider Allowed Benefit as payment in full

Bill CareFirst members only for deductibles, copayment, coinsurance, and non-covered services

D irect care of PPN patients to other PPN providers

N otif y CareFirst if an out of network referral is required

E nsure that the managed care provisions of the contract are met

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Eligibility Preferred providers must meet CareFirsts credentialing standards.

Reimbursement Preferred providers agree to accept a Preferred Provider A llowed Benefit (PPA B) as pay ment in f u l l. Preferred prov iders may not bi l l t he pat ient for a mou nt s t hat exceed the PPAB for covered services. Subscribers are liable for non-covered services, deductibles, copayments and coinsurance.

Collection of Retroactively Denied Claims A prov ide r rei mbu rs ement may be of f s et aga i n st 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 /prov iders /for ms. Print t he 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:

CareFirst BlueCross BlueShield Provider Information and Credentialing Mailstop CG-41 10455 Mill Run Circle Ow ings 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 t he terms of t he current prov ider agreements, p ro v id e r s m u s t p ro v id e w r it t e n no t i f ic a t io n o f termination with 90 days notice.

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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)

WelcomeImportant Phone Numbers and AddressesMembership and Product InformationMembership Identification CardsTraditional ProductsPreferred Provider ProductsPPNPPO

Medicare Supplemental ProductsTEFRA

Network Claims ProductPatient information

Claims Submission ProcessMaryland Point of ServicePrimary Care ProviderSpecialist/ReferralDirect AccessClaims/BenefitsBlueCard ProgramWhere to Direct Inquiries

Policy StatementsCare ManagementMandatory Second Surgical Opinion (MSSOP) Utilization Control Program (UCP)/Utilization Control Program Plus (UCP+) Coordinated Home Care and Home Hospice Care Individual Case Management (ICM) Outpatient Pre-Treatment Authorization Plan (OPAP) Magellan Health Services

Administrative FunctionsInquiry ProcessClaims SubmissionsClaims OverpaymentTimely Filing of ClaimsPaper Claims SubmissionElectronic Claim Submission

Effective Follow-Up on Outstanding CareFirst BlueCross BlueShield Indemnity ClaimsStep-By-Step Instructions for Effective Follow-Up

Other Party LiabilityCoordination of Benefits (COB)SubrogationPersonal Injury Protection (PIP)Workers Compensation

Appeal ProcessProfessional Appeal ProcessProfessional Grievance ProcessNecessary Information for both Appeals and GrievancesCarefirst.com Resources

HIPAA Compliant CodesIn-Office Injectable Drugs Standard Reimbursement MethodologyParticipating Provider Agreement (PAR)EligibilityPhysician AssistantsReimbursement Allowances

Preferred Provider Agreements (PPN)EligibilityReimbursement

Collection of Retroactively Denied ClaimsChanges in Provider InformationTermination of Agreement

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