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BluePreferred 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.

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Approvals and Referrals

What services require prior approval or a referral?

Answer: You do not need a referral or prior approval to seek care from any CareFirst Select Preferred Provider. You may receive treatment from any CareFirst Preferred Provider. When the provider is in the CareFirst Select Preferred Provider network or the Preferred Provider network of any BlueCross and BlueShield (BCBS) plan, in-network benefits will apply to covered services. Preferred providers are responsible for obtaining any required authorizations.
When the provider is not in the CareFirst Select Preferred Provider network or the Preferred Provider network of another BCBS plan, out-of-network benefits will apply to covered services.

How do I get prior approval or a referral?

Answer: You do not need to obtain a referral or prior approval when seeking care from any CareFirst Select Preferred Provider. You may receive treatment from any Preferred provider. When the provider is in the CareFirst Select Preferred Provider network or the Preferred Provider network of any BlueCross and BlueShield plan, in-network benefits will apply to covered services and the provider is responsible for obtaining any necessary authorizations.
When the provider is not in the CareFirst Select Preferred Provider network or the Preferred Provider network of another Blue Cross and Blue Shield plan, out-of-network benefits will apply to covered services and you are responsible for obtaining necessary authorizations that may be required for inpatient care or outpatient mental health services. Your can request an authorization for care by calling the appropriate authorization telephone number on the back of your ID card.

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

Answer: Preferred providers are responsible for obtaining any necessary authorizations. If you are seeking care from a provider that is not a Preferred Provider and you do not obtain a required authorization, benefits may be reduced or denied completely.

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Claims

How do I file a claim?

Answer: An advantage of your BluePreferred coverage is that you do not have to file claims when treatment is given by a Preferred Provider. All you have to do is pay any applicable copayment, coinsurance and/or deductible at the time of the visit.

If you do need to submit a claim for consideration of services rendered by a provider that does not participate in a BlueCross BlueShield Provider network, you may contact Member Services at the telephone number on the front of your ID card and request a CareFirst Health Benefits Claim Form.

 

How long do I have to file a claim?

Answer: Generally, all member submitted claims must be filed within 15 months 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 Certificate of Coverage.

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

Answer: Providers are reimbursed according to a fee schedule for covered services. Once a provider submits a claim and benefits are considered by the Plan, an Explanation of Benefits detailing your liability is sent to you. You may also contact Member Services at the telephone number on the front of your ID card to get additional information related to your claim liability.

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 you pay before CareFirst pays benefits. The benefit period deductible amount can be per person or per family (e.g., you need to pay for $250 of your care, based on CareFirst’s allowed benefit, before your benefits coverage begins). A copayment is the dollar amount that you pay for a certain covered service (e.g., you pay $10 when you visit the doctor).

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 directly to the nearest emergency facility. In an urgent (not life- or limb-threatening situation), we recommend that you contact your physician for advice or to arrange for treatment.

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 remain covered under your employer’s health plan. Also, 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.

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

Answer: If you move out of the area, BluePreferred enables you to access the BlueCard® program. Through the BlueCard® program, the same advantages are provided to members who live, work or travel outside of the BluePreferred service area. This is done by utilizing the Blue Cross Blue Shield national network.

The BlueCard® participating providers have agreements to accept our payment (after the member's coinsurance and deductible) as payment in full. With BlueCard®, if you obtain services through a preferred provider, you will receive benefits at the in-network level. If you choose not to see a BlueCard® preferred provider, benefits will be administered at the out-of-network level.

Call BlueCard® at 1-800-810-BLUE (2583) to obtain names of participating preferred providers in the area. This number is printed on the back of your ID card.

To confirm that you have BlueCard® access, look on your ID card for a "suitcase" emblem with "PPO" printed inside.

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.

Is my child covered while in college?

Answer: Please contact Member Services at the telephone number on your ID card to update your information or fill out a Member Change form.
For coverage out of the area, BluePreferred enables you to access the BlueCard® program. Through the BlueCard® program, the same advantages are provided to members who live, work or travel outside of the BluePreferred service area. This is done by utilizing the Blue Cross Blue Shield national network.

The BlueCard® participating providers have agreements to accept our payment (after the member's coinsurance and deductible) as payment in full. With BlueCard®, if you obtain services through a preferred provider, you will receive benefits at the in-network level. If you choose not to see a BlueCard® preferred provider, benefits will be administered at the out-of-network level.

Call BlueCard® at 1-800-810-BLUE (2583) to obtain names of participating preferred providers in the area. This number is printed on the back of your ID card.

To confirm that you have BlueCard® access, look on your ID card for a "suitcase" emblem with "PPO" printed inside.

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 my child living away at school?

Answer: Please refer to your Evidence of Coverage booklet to determine the age limit for children to remain covered under your employer's health plan. 
BluePreferred enables you to access the BlueCard® program. Through the BlueCard® program, the same advantages are provided to members who live, work or travel outside of the BluePreferred service area. This is done through the Blue Cross Blue Shield national network. 

The BlueCard® participating providers have agreements to accept our payment (after the member's coinsurance and deductible) as payment in full. With BlueCard®, if you obtain services through a preferred provider, you will receive benefits at the in-network level. If you choose not to see a BlueCard® preferred provider, benefits will be administered at the out-of-network level. 

Call BlueCard® at 1-800-810-BLUE (2583) to obtain names of participating preferred providers in the area. This number is printed on the back of your ID card. 

To confirm that you have BlueCard® access, look on your ID card for a "suitcase" emblem with "PPO" printed inside.

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.

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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 nine 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 continue to use the subscriber’s number.

Will I receive a new member ID card?

Answer: Yes, as soon as your new number is assigned, you will receive a new member 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 member 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 member 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 member ID card to my doctor?

Answer: Yes, show your new member 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 member ID card?

Answer: 1. When you receive your new member 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 Certificate of Coverage. You may also call Member Services at (202) 479-1739 to obtain specific information on contract benefits.

How and when can I contact the health plan?

Answer: Member Services representatives are available Monday-Friday, 7 a.m. - 7 p.m., EST, at 202-479-1739 or toll-free at 800-424-7474 (ext. 1739) TTY: 202-479-3546. You may also send written correspondence to:


CareFirst BlueCross BlueShield
BluePreferred Member Services
550 12th Street, SW
Washington, DC 20065

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 a network provider?

Answer: BluePreferred uses CareFirst’s Select Preferred Provider network. To determine if a provider is a CareFirst Select Preferred Provider or to locate a participating physician in your area, you may search our online provider directory or the most up-to-date provider listing available or call a Member Services Representative at 202-479-1739. 

What are the advantages of using network providers?

Answer: By using network providers, you will receive a higher level of benefits, your out-of-pocket expense will be less, and you will not have to fill out any claim forms. Your providers will obtain any precertifications you may need.

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

Answer: If you need to go outside of the network for care, you may choose from over 20,000 health care providers across the region that participate with CareFirst BlueCross BlueShield. You may still need to satisfy a deductible and pay coinsurance. Your coinsurance may be higher because these providers are not in the BluePreferred Provider Network.
If your physician does not participate with CareFirst, you may be responsible for direct payment to the provider and your deductible and coinsurance.

Do I need to select a primary care physician (PCP)?

Answer: BluePreferred members are not required to select a PCP. Therefore, you may change your practitioners at any time.

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

Answer: If you need to go outside the network for care, you may choose from over 20,000 health care providers across the region that participate with CareFirst BlueCross BlueShield. You may choose to get care from a provider who is not in the network; however you may still need to meet a deductible and pay coinsurance. Your coinsurance may be higher because these providers are not in the Select Preferred Provider Network.

Can I go to a non-network provider?

Answer: Yes. If you need to go outside the network for care, you may choose from over 20,000 health care providers across the region that participate with CareFirst BlueCross BlueShield. You may still need to meet a deductible and pay coinsurance. Your coinsurance may be higher because these providers are not in the BluePreferred provider network.
If your physician does not participate with CareFirst you may be responsible for direct payment to the provider, and for your deductible and coinsurance.

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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 and for covered services given by practitioners participating in the Preferred Provider network of another Blue Cross and Blue Shield plan. The BlueCard program puts you in touch with local network providers. Call BlueCard Access at 1-800-810-BLUE for a list of participating providers.
Out-of-network benefits are considered for non-emergency/urgent treatment if received from providers that do not participate in the Preferred Provider network of a Blue Cross and Blue Shield plan.

What emergency coverage do I have while I am traveling?

Answer: You will receive in-network benefits for emergency care.

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