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BlueChoice Opt-Out Open Access Frequently Asked Questions

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Appeals and Complaints

What is the procedure for lodging a complaint against a provider?

Answer: Contact a Member Services Representative at the number on your member ID card. A representative will record your concerns and may request a written summary of the issues. Our Quality Improvement department will investigate your concerns, share those issues with the provider involved and request a response. We will then communicate to you a summary of our findings.

How do I appeal a certification or authorization denial?

Answer: Contact Member Services at the number on the front of your member ID card.

How do I appeal a claim payment or denial?

Answer:

Step 1: Contact Us
Call the Member Services phone number on your member ID card. If your concern is not resolved through a discussion with a CareFirst BlueCross BlueShield (CareFirst) representative, you may submit a written appeal.

Step 2: Submit A Written Appeal
CareFirst must receive your written appeal within 180 days of the date of denial of benefits or services. Submit a letter addressed to the Member Services Department describing your reasons for appeal. Send the letter to the address that appears on your Member ID card. If you need help in finding the address,call or e-mail Member Services.

In the letter, include:

  • Member name and ID number
  • Provider name
  • Date(s) of service
  • Admission and discharge date if applicable
  • A copy of the original Explanation of Benefits, voucher or bill
  • Medical records (e.g. Emergency room records or X-ray reports)

In the event you are unable to put the request in writing, a Member Services representative can assist you. Or, ask your provider if they can submit this information for you.

Step 3: Appeal Decisions
All appeal decisions will be sent to you in writing and will include a detailed explanation about the decision, as well as any documentation to support the decision. You will also receive information on next steps you may take if you are not satisfied with the appeal decision.

*Please note that state mandates may alter the steps above.Refer to your Evidence of Coverage for more information regarding your appeal process.

Is there a procedure for handling an urgent or emergency appeal?

Answer: There is an emergency appeal process when:

  • The situation involves a prospective denial (a denial that involves treatment or services that have not yet been received); and
  • The health care services are necessary to treat a condition or illness that, without immediate medical attention, would seriously jeopardize the life or health of you or your ability to regain maximum function, or would cause you to be in danger to yourself or others.

The emergency appeal will be answered within 24 hours of the request to CareFirst.

My Explanation of Benefits says I received services that I did not have. What should I do?

Answer: Contact Member Services at the number on your member ID card.

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Approvals and Referrals

What services require prior approval or a referral?

Answer: You do not need a referral from your Primary Care Physician (PCP) to get in- or out-of-network care for covered services. However, you will need approval from Care Management for some services. These services would include non-emergency hospitalization and outpatient hospital services. In addition, chiropractic services need to be approved before the first visit. Also, Outpatient Mental Health and Substance Abuse Services must be pre-authorized by CareFirst BlueChoice's Mental Health Management Program. Refer to your Evidence of Coverage booklet to determine other services that may require prior authorization. Call Member Services at the telephone number on your ID card to verify if coverage exists for the specialty care you are seeking.

How do I get prior approval or a referral?

Answer: Your Primary Care Physician (PCP) can help coordinate your care and if your plan requires a PCP referral, your PCP will refer you to a specialist within the CareFirst BlueChoice network. CareFirst BlueChoice providers are responsible for obtaining any necessary authorizations.

What if I don’t get prior approval or a referral?

Answer: You do not need a referral from a Primary Care Physician (PCP) to seek in or out-of-network care. However, benefits for covered services could be considered at the out-of-network level. This will occur when you need an authorization and you or your provider do not obtain one.

How do I know which specialist I can use? Can I use any specialist in the CareFirst BlueChoice Provider Directory?

Answer: Yes, you can use any specialist you wish. However, you have lower out-of-pocket costs when you receive care from providers in the CareFirst BlueChoice network. You may also receive care from any provider outside the CareFirst BlueChoice network, but you will pay a higher out-of-pocket cost.
Your Primary Care Physician (PCP) can help coordinate your care and determine if the services of a specialist are necessary. Call Member Services at the telephone number listed on your Member ID card to verify if coverage exists for the specialty care you are seeking.

Please note that the CareFirst BlueChoice Provider Directory may list specialists whose services are not included within your particular plan.

Do I need a referral to see an obstetrician or gynecologist (OB/GYN)?

Answer: No. You can seek care from a CareFirst BlueChoice OB/GYN without a referral from your primary care physician (PCP).

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Claims

How do I file a claim?

Answer: An advantage of CareFirst BlueChoice coverage is that you do not have to file claims when treatment is given by a CareFirst BlueChoice network provider. All you have to do is pay any applicable copayment at the time of the visit.
If you do need to submit a claim of services performed by a provider outside of the CareFirst BlueChoice network (i.e. emergency care received outside of the service area), you may contact Member Services at the telephone number on your ID card to obtain a CareFirst BlueChoice Health Benefits Claim Form. Refer to your Evidence of Coverage for more information.

How long do I have to file a claim?

Answer: Generally, all member submitted claims must be filed within 90 days of the date of treatment. Be sure to attach a complete itemized bill prepared by the provider of service that includes the charges for each service along with the medical condition for which the treatment was performed. You should verify the filing period for your coverage by reviewing your Evidence of Coverage.

A provider has billed me; how do I know how much of the bill to pay?

Answer: CareFirst BlueChoice providers receive benefit payments according to a fee schedule for covered services. You may contact Member Services at the telephone number on the front of your ID card to obtain additional information related to your copayment or other liability to the provider.

How can I check the status of my claim?

Answer: You may contact Member Services at the telephone number on your member ID card or in the My Account section.

What is the difference between deductibles and copayments?

Answer: A deductible is a dollar amount of incurred covered expenses that you pay before CareFirst BlueChoice pays benefits (i.e. $500 deductible). A copayment is a specified dollar amount that you pay for a certain covered service based on the type of provider or care (e.g., you pay $10 when you visit the doctor for routine medical care).

How does my out-of-pocket maximum work?

Answer: Once your out-of-pocket expenses for incurred covered services have reached the benefit period limit specified in your Evidence of Coverage, the plan pays 100% of the allowed benefit for your eligible expenses for the rest of that benefit period.

What is Coordination of Benefits (COB)?

Answer: COB is the process of determining the order of benefit responsibility when a member has health care coverage under more than one plan, such as coverage under his/her own plan, as well as that of a spouse. The purpose is to prevent double payment for one service.

Why did I receive a Coordination of Benefit questionnaire? Do I have to return it?

Answer: This form tells CareFirst whether it must coordinate payments with any other health coverage, such as through a spouse. Yes, you must return this form in order to prevent any delays in processing claims.

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Emergency Care

What do I do in case of an emergency?

Answer: If you believe a situation is a medical emergency, call 911 immediately or go to the nearest emergency facility. In an urgent (not life- or limb-threatening) situation, we recommend that you contact your PCP. If your PCP is not available, call FirstHelp, our 24-hour Emergency Assistance and Medical Advice Service at 800-535-9700 (This telephone number is also listed on the back of your card).

Do you cover emergency care?

Answer: Yes, in-network benefits are available for the treatment of medical emergencies or accidental injuries.

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Enrollment

How can I cover my newborn from birth?

Answer: Changes in family status allow you to adjust your coverage. Notify your employer or CareFirst of the birth of your newborn within the time frame specified in your Evidence of Coverage booklet.

How do I obtain coverage for my newly adopted child?

Answer: Changes in family status allow you to adjust your coverage. Notify your employer or CareFirst BlueChoice of the adoption within the time frame specified in your Evidence of Coverage booklet.

How do I add or delete coverage for family members?

Answer: You can only add or delete a family member during open enrollment, unless you have a qualifying "life event." Life events include, but are not limited to, births, deaths, adoption and divorce. Please notify your employer of the change in coverage. Also, contact CareFirst at the Member Services telephone number on your member ID card. You will need to fill out a Membership Change Form or New Enrollment Form. For more information, please refer to your Evidence of Coverage booklet.

How often can I change benefit plans?

Answer: Generally, you may only change benefit plans during your employer’s open enrollment period unless you have a special change in circumstance. Please refer to your Evidence of Coverage booklet for more details

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General Information

What happens to my coverage if I quit my job or I'm laid off or fired?

Answer: Generally, your benefits end on the last day of the month that you worked. Please contact your employer to find out if you have the option to continue coverage. This coverage would occur at your own cost through the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) or state continuation of coverage provision where applicable. Please refer to your Evidence of Coverage booklet for more details.

What happens to my coverage if I turn 65?

Answer: If you are still an active employee at your company, your coverage usually continues when you turn 65. In addition, you may also become eligible for Medicare. Please refer to your Evidence of Coverage booklet for more details.

What happens to my coverage if I retire?

Answer: If you retire prior to age 65, you may be eligible to keep coverage under your employer’s health plan. In addition, under certain conditions as a retiree, you may be able to keep coverage when your benefits are cancelled. Please contact your employer for more information.

Is my child covered while in college?

Answer: If the college is outside of the CareFirst BlueChoice service area, coverage is limited to emergency and urgent care only. Other covered services received outside the CareFirst BlueChoice service area will receive coverage at the out-of-network level. Please refer to your Evidence of Coverage booklet for more details.

How do I obtain a copy of my Certificate of Coverage?

Answer: You can:
a) Contact the plan administrator if you are in a group plan; or
b) Call Member Services if you have individual coverage

What if I become disabled?

Answer: Please refer to your Evidence of Coverage booklet for more details about coverage should you become disabled.

What happens to my coverage if I move out of the area?

Answer: To be eligible for coverage you must live or work in the CareFirst BlueChoice service area. If you move outside of the service area, your coverage may end with 31 days written notice to you.

What if my spouse and I divorce?

Answer: Please contact your employer to learn if your spouse can continue coverage. This coverage would occur at your own cost through the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) or state continuation of coverage provisions where applicable. Refer to your Evidence of Coverage for more details.

Can I cover a dependent who lives out-of-state or is away at school?

Answer: Dependents who live or attend school outside the CareFirst BlueChoice service area are eligible for in-network benefits for emergency or urgent care only. Other covered services received outside the CareFirst BlueChoice service area are eligible for coverage at the out-of-network level. Refer to your Evidence of Coverage booklet for more details.

Do I have coverage for pre-existing conditions?

Answer: Generally, yes. Please refer to your Evidence of Coverage booklet for more details.

How long can my children remain covered?

Answer: Your children remain covered until they marry or until they reach the age limit found in your Evidence of Coverage booklet.

How long can my child be covered if he or she has disabilities?

Answer: As long as your disabled child was covered before reaching the plan’s limiting age, coverage continues for as long as you are covered under the plan. Please refer to your Evidence of Coverage booklet for more details.

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ID Cards

How do I order additional ID cards?

Answer: Additional ID cards can be ordered several ways.

Do I need to carry my ID card with me at all times?

Answer: Always carry your ID card with you and present it wherever you receive care. Our Member Services telephone number is on the front of your card. The back of the card lists other important telephone numbers to help you in accessing care. Your ID card includes the name of your PCP and the copayment amounts for PCP, specialist and emergency room visits.

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ID Number Conversion to Non-SSN

Why is CareFirst replacing my identification (ID) number?

Answer: Identity theft using Social Security numbers is a growing problem. To protect your privacy and security, CareFirst is in the process of replacing all subscriber* ID numbers with numbers not based on your Social Security number.

*A subscriber is the person who holds a contract with CareFirst . A member is anyone in the subscriber's family who may be covered under that contract.

What will my new number look like?

Answer: Your new number will continue to begin with an alpha prefix followed by 9 numeric digits (e.g. XIC987654321).

Will my dependents receive new ID numbers as well?

Answer: Only the subscriber who holds the contract with CareFirst will receive a new ID number. All dependents covered under the contract will use the subscriber’s number.

Will I receive a new ID card?

Answer: Yes, as soon as your new number is assigned, you will receive a new ID card. Please continue to use your current ID number and card until the new card arrives. Due to the large number of subscribers affected, the process will continue throughout 2005.

Will CareFirst still use my Social Security number?

Answer: Yes, CareFirst will still continue to use your Social Security number internally. We may also require you to provide your Social Security number on documents such as enrollment forms, and Flexible Spending Account forms. CareFirst has adopted and enforces a strict Privacy Policy intended to safeguard the confidentiality of information that is necessary to operate our business.

What if I live in a state where legislation banning the use of Social Security numbers has already been passed?

Answer: If you live in one of these states, you will receive a new ID number and card according to your state’s legislative requirements. If you believe that you should have received a new ID number and have not yet, please contact your HR benefits administrator or call Member Services at the phone number listed on your ID card.

Does my doctor know to use the new number when submitting my claims?

Answer: We are informing doctors and other health care providers that we are changing your ID number and they should submit the new ID number on claims. However, you should always show your ID card to your doctor or health care provider at every visit.

If I submit my own claims, what number should I use?

Answer: Include the new ID number on your claim to ensure the claim is filed accurately and to minimize claim payment delays.

Should I show my new ID card to my doctor?

Answer: Yes, show your new ID card to your doctor and other health care providers at your next visit. The information on the card will enable the provider to file the claim accurately and minimize claim payment delays.

What should I do when I receive my new ID card?

Answer:

1. When you receive your new ID card, take a moment to review the information on it. If you find that your information is listed incorrectly please contact the Member Services Department at the number listed on your ID card
2. Destroy your old ID card upon receipt of the new card
3. Show your new ID card to your doctor and other health care providers at your next visit

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Member Services

How do I get additional information about my plan or benefits?

Answer: Your benefits are detailed in your individual or group's Evidence of Coverage. You may also call Member Services at the telephone number on the front of your ID card to obtain specific information on contract benefits.

How do I change my name or address?

Answer: Call your Member Services Representative at the telephone number on the front of your ID card to change your name or address.

What are your Member Services hours?

Answer: Our Member Services department is available Monday - Friday, 7 a.m. 7 p.m., EST.

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Pharmacy

What is the difference between generic and brand name drugs?
How does that difference affect my benefits?

Answer: A brand name drug is a prescription drug that has been patented and is only available through one manufacturer or distributor. A Generic drug is any drug approved by the Food and Drug Administration (FDA) that has the same bio-equivalency as a specific brand name drug. The copayment for a Generic drug is generally lower than that of a brand name drug. Refer to your Evidence of Coverage for more details.

If a Generic drug is available and you purchase a Non-Preferred Brand drug, you will pay the generic copay PLUS the difference between the Generic and the Non-Preferred Brand drug cost.


If a Generic is not available, you pay only the applicable Preferred drug copay if a brand name drug is on CareFirst's Preferred Drug List. Otherwise, you will pay the Non-Preferred Brand drug copay.

For more information, visit CareFirst's Drug Coverage.

Can I get reimbursed for drugs I got from a pharmacy not in the network?

Answer: Yes. You can use nonparticipating pharmacies, but you will have to pay for the full cost of the drug at the time of purchase, then submit a claim form for reimbursement. Your benefits may not reimburse the full cost of the prescription. Please refer to your Evidence of Coverage booklet for more details.

How do I get prescriptions filled through a mail order pharmacy?

Answer: You can learn more about the mail order prescription program by clicking Prescription Drug Tools in our Resource section.

If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period?

Answer: If you are traveling out of town for less than one month, call CareFirst's Pharmacy Services at (800) 241-3371 to get approval for an additional short-term supply.

If you need to request additional quantities (greater than one month), please contact CareFirst or CareFirst BlueChoice Member Services at the telephone number on your member ID card.

Please call 10 days in advance of your departure to request the additional supply.

What is the Preferred Drug List and how does that affect me?

Answer: The Preferred Drug List is the list of brand name and generic drugs published by CareFirst and used by participating providers and licensed pharmacists when writing and filling prescriptions. All Generic drugs are included on the Preferred Drug List. Not all brand name drugs are included in the Preferred Drug List. This list may be changed periodically by CareFirst without notice to members. A copy of the Preferred Drug List is available to you upon request.

Selected for their performance and affordability, Preferred drugs include both Generic and Preferred Brand drugs.

Non-Preferred Brand drugs are not part of the Preferred Drug List, but are covered by your pharmacy benefits.

For more information, visit our Drug Coverage section.

How do I get a list of Preferred Drugs?

Answer: Please review the information online in our Drug Coverage section. Or, call the prescription drug vendor at the telephone number on your member ID card.

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Physicians and Other Providers

How do I find an in-network provider?

Answer: To determine if your provider participates in the CareFirst BlueChoice network, or to locate a participating physician in your area, you may search our online provider directory for the most up-to-date provider listing available. This directory is updated every 15 days. You may also call Member Services at the telephone number on your ID card. A representative can answer your questions directly or mail you a provider directory .

What is a primary care physician (PCP)?

Answer: A PCP is the physician selected by the member, who provides routine care and coordinates other specialized care. The PCP must be selected from the CareFirst BlueChoice network. The physician you choose as your PCP may be a family or general practitioner, internist or pediatrician.

What are the advantages of using network providers?

Answer: Your CareFirst BlueChoice Opt-Out coverage provides benefits for covered services rendered by network and non-network providers. You will pay a lower out-of-pocket cost when you receive care from providers who participate in the CareFirst BlueChoice network. You may also receive care outside the CareFirst BlueChoice network, from any provider, but you will pay a higher out-of-pocket cost. In addition, network providers agree to file all claims and obtain any necessary authorizations you may need.

How do I know if my doctor is a CareFirst BlueChoice primary care physician (PCP)

Answer: To determine if your doctor is a CareFirst BlueChoice PCP, or to locate a PCP in your area, you may:

  • Search our online  provider directory for the most up-to-date provider listing available. 
  • Call Member Services at the telephone number listed on your Member ID card. They can answer your questions directly or mail you a provider directory.

What happens if my current physician is not a network provider?

Answer: You will need to select another PCP who is in the CareFirst BlueChoice network. You may want to make an initial appointment with him or her so you can get to know each other and review your medical history.

How do I change my primary care physician (PCP)?

Answer: You can change your PCP by calling Member Services at the telephone number on the front of your ID card. CareFirst BlueChoice must be notified and must process the PCP change prior to the time you receive care from the new PCP.

Can I change my PCP any time I want?

Answer: Yes. You can change your PCP by going online or by calling Member Services at the telephone number on your ID card. CareFirst BlueChoice must be notified and must process the PCP change prior to the time you receive care from the new PCP. If the change is requested prior to the 20th of the current month, it will be effective on the first day of the following month. Requests received after the 20th of the current month will be effective on the first of the second month following your request.

What if a primary care physician cannot see me right away?

Answer: CareFirst BlueChoice has set goals for practitioners in our participating networks regarding appointment availability and office waiting times. For appointments for non-symptomatic visits, such as preventive care or routine wellness, we expect that the appointment with the doctor should be scheduled within four weeks. If you have an urgent problem, call your PCP as soon as possible, and the office staff will arrange an appropriate time for you to be seen. For a symptomatic (acute) problem, most offices try to schedule you within 24-72 hours or less, depending on the urgency of the problem. The nurse or the appointment staff at your doctor’s office will help you determine how quickly you need to be seen.

What if a network provider isn’t available to treat my condition?

Answer: If a provider with the required specialty is not available within the CareFirst BlueChoice network, you or your PCP should contact CareFirst BlueChoice to determine if authorization is available for treatment by an out-of-network specialist.

Can I go to a non-network provider?

Answer: Yes, you may receive care from a covered non-CareFirst BlueChoice network provider; however, benefits for covered services will be considered at the out-of-network level. You will be responsible for a percentage of the plan allowance and any provider charges above that amount.

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Travel Coverage

What routine coverage do I have while I am traveling?

Answer: In-network benefits are available for emergency or urgent care only. For non-emergency or non-urgent care when you are outside of the CareFirst BlueChoice service area, benefits for covered services are considered out-of-network. You will be responsible for a percentage of the plan allowance and any provider charges above that amount.

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