Carefirst ucp

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Specialists should verify the validity of a referral prior to rederig services. Direct Access Geera l ly cer tai ser v ices ca be obtaied w it hout a referral from the PCP ad still be processed as i-etwork services. These ser vices are referred to as direct access ser v ices.

Please keep i mid that beef its for these services would still eed to be verified by the appropriate provider service area. Paper claims are to be submitted to the ormal CareFirst add re s s. Some of your patiets may have the Triple Choice product. Level oe of this product provides the highest level of beefits ad 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 redered by a CareFirst participatig provider or o-participatig provider ad offers the lowest level of beefits. Prov iders located i Mar ylad should fi le claims based o the followig : Provider is participatig with CareFirst s Marylad etwork oly. Claims should be submitted to the pla where the subscriber has membership.

Claims for CareFirst subscribers who hold a Marylad membership card ad subscribers of BCBS plas that the provider does ot participate with must be submitted to CareFirst. The BlueCard program also requires that participatig providers bill the patiet oly for their share of covered ser v ices deduc t ibles, copay met s, a d coisura ce amouts based o CareFirst s allowed beefit.

Most plas take advatage of the ability to assig the third letter ad use it to assist with claims directio ad cotract idetificatio.

It is critical to claims processig for out-of-state subscribers that the pref ix appears o the claim form. The pref i x should be obtaied from the subscriber s idetificatio card, whe possible. Iclude the prefix for both paper ad electroic claims. If you are ot certai where to idicate the prefix whe filig electroically, please cotact your Electroic Data Iterchage EDI vedor. Where to Direct Iquiries Beefits ad eligibility ca be verified by cotactig the pla through which the patiet is erolled.

To do this, call toll free ad you will be directed to the appropriate BCBS pla. It is importat to obtai the 3-letter prefix from the subscriber s ID card prior to usig this umber. Claim status iquiries ca be directed to CareFirst. It also provides reassurace to patiets havig elective surgery by either cofirmig the eed for the surgery or advisig them of other forms of treatmet.

The program applies to a specific list of diagostic ad surgical procedures whe they are performed o a elective, o-emergecy basis. To verif y procedures, check BlueLie. These programs feature pre-admissio review, admissio review, cotiued stay review, retrospective review, ad discharge plaig. Coordiated Home Care ad Home Hospice Care The Coordiated Home Care ad Home Hospice Care programs allow recoverig ad termially ill patiets to stay at home ad receive care i the most comfortable ad cost-effective settig.

I order to qualif y for program beefits, the patiet s physicia, hospital or home care coordiator must submit a treatmet pla to CareFirst. A licesed home health agecy or approved hospice facility must reder eligible services.

Oce approved, the home health agecy or hospice is resposible for coordiatig all services. Idividual Case Maagemet ICM ICM is a volutary program available to those members who have acute illesses i a variety of specialt y areas icludig Aquired Immue Deficiecy Sydrome AIDS , ocolog y, eoatolog y, pediatrics, high-risk obstetrics, head ijur y, spial cord ijury as well as medicie ad surger y.

Case maagemet ser ves to coordiate a d support services that are aimed at assistig the member s attaimet of short-term health objectives ad log-term goals.

Health care providers, patiets, family members, employers or ayoe familiar with the case may refer cadidates for ICM see Importat Telephoe Numbers. The provider of care must complete a form that icludes the patiet s diagosis ad expected legth of treatmet. The form will the be reviewed, ad the provider ad subscriber will receive writte otificatio of the decisio.

Magel la offers programs desiged with a patiet-advocacy focus such a s Ca re Ma agemet a d e ha ced ut i l i z at io maagemet. Care Maagemet is Magella s etwork-based cliical ser v ice prog ra m. It combi es t he best at t r ibutes of ut i l i z at io ma agemet w it h t he cl i ica l sk i l ls a d ex per iece of a ca re ma agemet tea m t hat g u ides referrals ad serves as a patiet s advocate through the etire episode of care.

Ehaced Utilizatio Maagemet is a utilizatio review process that works with each member s provider to esure medically-ecessary treatmet i the most appropriate settig. May iquiries ca be hadled to the providers satisfactio i the appropriate Provider Services area. If the iquiry caot be satisfied i t he Ser v ice area, t he prov ider w ill be istructed to submit a writte iquiry o a Provider Iquiry Resolutio Form PIR F to documet the reaso for t he request alog with pertiet or supportive records, literature or claims documetatio to CareFirst Provider Services.

These sectios are especially helpful i describig multiple claims billig guidelies, icludig but ot limited to Modifier Reimbursemet Guidelies, Bilateral Procedures Reimbursemet Guidelies, Team Surgery ad Prevetive Services. Claims Submissios I accordace with Mar ylad law addressig uiform claim form submissio, al l hea lth care practitioers licesed or certified uder the Health Occupatio Article, Aotated Codes of Marylad must use the Ceters for Medicare ad Medica id Ser v ices CMS as t he stadard claim form.

I additio, providers should use the CMS istructios for completig the form whe filig for professioal services. Box Ba ltimore, Md Please iclude the membership umber, patiet ame, claim umber ad the reaso for the refud with your check. Timely Filig of Claims To be cosidered for paymet, claims must be submitted withi days from the date of service. Recosideratio: Claims submitted beyod the timely filig limits geerally are rejected as ot meetig these guidelies.

If your claim is rejected, but you have proof t hat the claim was submitted to CareFirst w ithi t he guidelies, you may request processig recosideratio.

Documetatio is required for this process. Timely filig recosideratio requests must be received withi six moths of the provider receivig the origial rejectio otificatio o the provider voucher or otice of paymet. Requests received af ter six moths will ot be accepted ad the charges may ot be bil led to the member.

For electroic claims : A cofirmatio from the vedor or clearighouse that CareFirst successfully accepted the claim. Error records are ot acceptable documetatio. For paper cla ims : A scree prit f rom t he prov ider s computer idicatig the origial bill creatio date alog with a duplicate of the clea claim or a duplicate of the origially submitted clea claim with the sigature date i field 12, idicatig the bill creatio date.

Successful imagig of the claim depeds o prit darkess. Light prit produces uacceptable imagig a d your cla im may be retured to you. Please ma ke sure to chage typewriter ribbos or priter cartridges regularly so that the prit is dark. Icomplete claims create uecessar y processig ad paymet delays for all providers. The fields listed below must be completed o all claims submitted to CareFirst. Submittig a duplicate of a claim already i process w ill geerate a rejectio, which will cause a backlog of uecessar y claims to be processed.

FEP membership umbers do ot have a 3-digit prefix, but begi with a R ad have 8 umeric digits. C l a i m s t h a t a r e s u b m i t t e d o photocopies or forms other tha a origial CMS require maual iput, which may result i processig delay. A l l iformatio must fit properly i the blocks provided. Electroic Claim Submissio Electroic cla ims submissio is t he automated f ilig of claims uti lizig a computer sof t ware package ad trasmittig the claims electroically.

See page 7 for a list of electroic claims submissio vedors. You may check ay time after the receipt of a Medicare Remittace Notice If there is o record of the supplemetal claim, please follow these steps: Submit a copy of the Medicare Remittace Notice attached to a copy of the HCFA form.

Be sure that the CareFirst provider umbers are idicated o the HCFA form appropriately Mail to the appropriate claims address If the claim has bee pedig for more tha 30 days, please cotact the appropriate provider customer service uit for assistace.

COB is applied wheever a member covered uder a CareFirst cotract is a lso eligible for healt h isurace beef its t hrough aother isurace compay or Medicare. However, the member may be billed for ay deductible, coisurace, o-covered services or services for which beefits have bee exhausted. These charges may the be submitted to the secodary carrier for cosideratio.

However, geerally CareFirst s stadard method of providig secodary beefits for covered services is the differece betwee the higher allowed beefit ad the amout paid by the primary carrier as log as the differece does ot exceed CareFirst s allowed beefit, except whe Medicare is primary.

Claims for secodar y beefits must be accompaied by the explaatio of beefits EOB from the primar y carrier. Such actio will ot affect the submissio ad processig of claims, ad all provisios of the participatig provider agreemet apply.

Persoal Ijury Protectio PIP PIP is a automobile isura ce prov isio t hat covers medica l ex peses a d lost wages experieced by the i su re d or pa s s egers a s a re su lt of a automobi le accidet.

W hi le Ma r yla d law wa s a meded i to requi re t his coverage for passegers ad family members uder the age of sixtee, most isureds choose to cotiue to cover other passegers uder this provisio i their automobile isurace cotracts.

Workers Compesatio This program is desiged to provide reimbursemet for workers who sustai ijuries or illesses arisig out of or i the course of employmet.

The Marylad Workers Compesatio Act excludes sole proprietors, parters a d of f icers of closed cor poratios from madator y coverage uder the act, givig them istead the optio to elect coverage. Verificatio from the subscriber of this waiver is required by CareFirst i order to process claims. Workers compesatio replaces health isurace. A participatig provider caot balace-bill CareFirst or the subscriber for ay amout ot covered uder workers compesatio.

Claims for workers compesatio should be filed to the workers compesatio carrier first ad to CareFirst oly after the workers compesatio carrier has determied that the charges are o-compesable uder workers compesatio. If workers compesatio determies that the charges are o-compesable, attach a copy of t he deia l from the workers compesatio carrier to the claim.

The CAU is the primar y cotact for appeals for iteral ad exteral auditig agecies. CareFirst has oe iteral level for the appeals process. Appeals must be submitted withi caledar days or six 6 moths, whichever is loger, from the date the adverse decisio was received. A letter describig the reaso s for the appeal ad the cliical justificatio or ratioale is required icludig the followig iformatio, if possible: Patiet s ame ad idetificatio umber Provider umber or tax idetificatio umber Admissio ad discharge date, if applicable or the date s of service The treatig physicia s ame The complete ipatiet medical record Relevat outpatiet records A letter of medical ecessity addressig specific related cliical iformatio.

Supportig cliical otes or medical records icludes pertiet lab reports, x-rays, treatmet plas ad progress otes. If the appeal icludes a request for review of acillary ser vices, the letter of medical ecessity should specifically state the medical ecessity of the acillary services o the deied days. If the appeal ivolves ipatiet days, a licesed physicia who is a member of the hospital s staff or a urse workig i cojuctio with the physicia should write the letter of medical ecessity.

If a urse writes the letter of medical ecessity, it should idicate the physicia s ivolvemet i the appeal 17 idemity iformatio PROVideR maual. A ex ped ited or emergec y appea l is defied as oe where a delay i receivig the health care ser vice could seriously jeopardize the life or health of the member or the member s ability to fuctio or cause the member to be a dager to self or others.

Expedited appeals may be faxed to A expedited appea l may iclude, but is ot limited to, a physicia to physicia or peer to peer rev iew, whe a adverse decisio has bee redered regardig a cocurret ipatiet leg th of stay. A emergecy icludes a ser vice ot yet provided i. We w i l l a swer a ex pedited or emergecy appeal w it hi 24 hours f rom t he date t he appeal is received. The grievace w il l be reviewed by a physicia ot ivolved i the iitial deial determiatio.

There is a full ad fair review process for all grievace decisios. Appeal or Grievace Resolutio Oce the iteral appeal process is complete, you will receive a writte decisio that will iclude the followig iformatio: The specific reaso for the appeal decisio. A referece to the specific beefit provisio, guidelie protocol or other criteria o which the decisio was based.

A statemet regardig the availability of all documets, records or other iformatio relevat to the appeal decisio, free of charge icludig copies of the beefit provisio, guidelie, protocol or other similar criterio o which the appeal decisio was based. Notificatio that the diagosis code ad its correspodig meaig, ad the treatmet code ad its correspodig meaig will be provided free of charge upo request.

Cotact iformatio regardig a State cosumer assistace program. Iformatio regardig the ext level of appeal, as appropriate. Whe a claim is deied for o authorizatio obtaied, this idicates there is ot a cotractually required pre-certificatio o fi le. To submit a paymet dispute for o authorizatio, give a specific reaso why precertificatio could ot be obtaied ad iclude the complete medical record We will retur requests for recosideratio without the above iformatio citig deial of paymet upheld, util the request is submitted with the iformatio eeded to complete the review.

These updates are made o a quarterly basis through the caledar year. Rei mbu rsemet for a l l i -of f ice i jec table d r ugs is updated quarterly o the first of February, May, August a d November. The rates are i ef fect for the etire qu a r ter but a re subje c t to cha ge e ach qu a r ter.

P4 Ocolog y ad P4 R heumatolog y fee schedules are ot icluded i this reimbursemet methodology. Participatig Provider Agreemet PAR The major terms of the PAR agreemet require that the provider: File claims o behalf of the member Oly request deductibles ad copaymets at the time of the service Accept the allowed beefit as paymet i full The provider will receive reimbursemet directly from CareFirst o their remittace.

Eligibility Most licesed hea lth care professioals a re eligible to participate. Physicia Assistats Covered services redered by Physicia Assistats PA a re el ig ible for rei mbu rsemet u der t he fol low i g circumstaces: PA is uder the supervisio of a physicia as required by local licesig agecies Services redered by the PA are submitted uder the supervisig physicia s ame ad provider umber CareFirst BlueChoice does ot cotract with Physicia A s si s t a t s.

Phy sic ia A s si s t a t s ser v ic e s a re to b e submitted uder the supervisig physicia s ame ad provider umber. Providers caot require the paymet of charges above ad beyod coisurace, copaymets ad deductibles. To help you evaluate your office s curret practices, our policy is below. Participatig providers shall ot charge, collect from, seek remueratio or reimbursemet from or have recourse agaist subscribers or members for Covered Services, icludig those that are iheret i the delivery of Covered Services.

The practice of chargig for of fice admiistratio ad expese is ot i accordace with the Participatio Agreemet ad Participatig Provider Maual.

However, the provider may look to the subscriber or member for paymet of deductibles, co-paymets or coisurace, or for providig specific health care ser vices ot covered uder the member s Health Beefit Pla as well as fees for some admiistrative services.

Such fees for admiistrative services may iclude, by way of example, fees for completio of certai forms ot coected with the providig of Covered Services, missed appoitmet fees, ad charges for copies of medical records whe the records are beig processed for the subscriber or member directly.

Preferred prov iders may ot bi l l t he pat iet for a mou t s t hat exceed the PPAB for covered services. Subscribers are liable for o-covered services, deductibles, copaymets ad coisurace. Collectio of Retroactively Deied Claims A prov ide r rei mbu rs emet may be of f s et aga i st a retroactively deied claim by a affiliated compay of CareFirst, Ic.

We realize that you are ot a ew provider, but you must use the ew CareFirst provider umber whe required. Termiatio of Agreemet Uder t he terms of t he curret prov ider agreemets, p ro v id e r s m u s t p ro v id e w r it t e o t i f ic a t io o f termiatio with 90 days otice. Registered trademark of CareFirst of Marylad, Ic. New job. Life is full of chages. Some are. Get More with Additioal Cardholders.

Importat iformatio. The legislative itet of SB is to reform the ustable property. For the cost of may of the thigs you buy each day, you ca have security ad peace of mid with health coverage from CareFirst BlueCross BlueShield CareFirst. Affordable log-term care coverage for both. Your rights uder Califoria Welfare Programs for people applyig for or receivig public aid i Califoria Tell us if you eed help because of a disability Ask for a free iterpreter 2 Your rights all people.

Please keep it i a safe place. The Isolvecy Service of Irelad is a idepedet. It requires us, Aego, to give you this importat iformatio to help you to decide whether. User guide e-trader user guide Itroductio At UK Geeral our aim is to provide you with the best possible propositio for you ad your customers.

We believe i offerig brokers a choice of how they trade with. This brochure. The amedig Regulatios. Makig traiig work for your busiess Itegratig core skills of laguage, literacy ad umeracy ito geeral workplace traiig makes sese. The iformatio i this pamphlet will help you pla for ad build a successful. For customers Icome protectio the facts We ve desiged this documet to give you more iformatio about our icome protectio beefits.

This iformatio refers. BSA has provided. Iformatio Hadbook This hadbook has bee desiged to aswer questios you may have about the admiistratio of your Health ad Detal Pla. Sectios are icluded o how to make a claim, whe to otify us of chages such. Commo Stock Best Buy Co. Cocordia Health Pla for Medicare. This brochure is.

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