Electronic Explanation of Benefits (EOB) Frequently Asked Questions
Answer: An Electronic Explanation of Benefits or E-EOB is a weekly summary of medical and dental claims that have been processed by CareFirst and CareFirst BlueChoice. E- EOBs will display details about claims processed for you, your spouse and/or dependents (if applicable).
Answer: E-EOBs are available in the My Account section of www.carefirst.com and have been redesigned to help you easily understand the claims that are processed in a weekly time period. E-EOBs can be viewed online and printed at your convenience.
Answer: Sometimes an e-mail from a new sender will automatically go to your spam or junk mail folder. To avoid this, when you receive an e-mail from CareFirst, add the sender e-mail to your address book or safe senders list. See your e-mail program's “Help” option for the proper location. Members must verify their e-mail address and opt-in to receive electronic forms of communication. Go to “My Profile” within My Account to update your email address and consent.
Answer: The document number is a unique identifier that is generated for each E-EOB so that it can be easily referenced and searchable online.
Enrollment and Access
Answer: You can visit the CareFirst website to register for My Account. Once online you can choose to receive weekly E-EOB notifications.
Answer: If you are a registered user of My Account, you can log-in and visit the EOB section of the site under “Manage My Plan”.
Answer: In some cases, there are confidentiality reasons why certain family member information is not available in an E-EOB. If there are no confidentiality reasons, as the subscriber, you have access to all E-EOBs for claims processed for you and your family by viewing, saving and/or printing a copy of the weekly summary.
Answer: You can access an E-EOB on My Account as often as you like.
Answer: Once available, E-EOBs will be accessible online for as long as 3 years.
Answer: Select “Contact Us” or “Communication Center” in the top header of My Account to send a secure e-mail to a CareFirst Customer Service Representative. You can also call the number on the back of your ID card to obtain a copy of an E-EOB that is no longer available online.
Answer: Yes. While E-EOBs will be available online in the fall of 2011, any E-EOBs created prior to your access to My Account site will not be included.
Answer: Once you sign up for E-EOB email notifications, in most cases you will no longer be mailed EOBs to your home via the U.S. Postal Service. In the instance that your EOB includes a check made payable to you, the subscriber, you will receive the EOB via the U.S. Postal Service. If an e-mail alert is attempted and fails for any reason, you may also begin to receive your EOBs via the U.S. Postal Service.
Answer: E-EOBs are processed on a weekly basis for finalized claims. If a claim is still pending (not completely processed) it will not be displayed on the E-EOB. There may be instances where the claim is listed as finalized in its status, but no PDF version is available. Check back in a few days to see if the printable EOB is available, as the system updates printable EOBs once a week.
Paper EOBs Availability
Answer: You may contact Member Services at the telephone number listed on your ID card to obtain a paper copy of an EOB. You can also print a copy of your E-EOB from the My Account site.
Answer: Yes. At any time you can visit My Account on the CareFirst website to change your e-mail notification preference. If you choose not to receive e-mail notifications, you will begin to receive EOBs via the U.S. Postal Service.
Answer: Claims that have been changed or adjusted can be compared by searching for claims by claim number on the search claims detail screen in the “Manage My Plan” section of My Account.
Answer: Claims that been overpaid by your insurance will be documented on the E-EOB. A separate box will display the claim number, the original payment amount, the adjustment or overpayment amount, and the remaining balance.
Answer: If the claim doesn't appear in the list after searching, here are a few things to try:
- If your doctor submits your claim, and it has been less than 15 days since the date of service, check My Account again in a few days.
- If it has been at least 15 days since the date of service, contact your doctor's office to make sure they submitted the claim.
- If you sent the claim yourself and it has been more than 15 days, double check your copy to make sure all of the information is correct (such as your member ID, group number, patient name, date of birth). If any information is incorrect, please send the claim again.
- If claims are still in pending status (not completely processed), please check back later to verify the claim is listed on the E-EOB once it is finalized.
- Select “Contact Us” in the top header of your My Account for more information on how to receive additional assistance.
Answer: Each claim is different and processing times will vary. The length of time it takes to process a claim depends on these factors:
- How soon your doctor or hospital submits the claim. Almost 80 percent of claims are received within 30 days from the date of service. In some cases, it can take up to 60 days before your doctor or hospital submits a claim.
- How quickly we process the claim once it’s received. More than 90 percent of claims are processed within 7 days of receiving them.
- Whether you have gone to an out-of-network doctor or hospital. If you have gone to an out-of-network doctor or hospital, two other factors may affect how long it takes to process your claim:
- Whether the doctor or hospital requires partial or full payment at the time of service.
- Whether the doctor or hospital can bill us directly or needs you to submit a medical claim form.
Remark Codes and Adjustments
Answer: On the E-EOB there will be a column noted as REMARK CODE. A Remark Code is typically a 4-digit number that references a special note on the E-EOB.
Answer: The Remark Code Explanation is found at the bottom of the E-EOB after all claims have been listed. It is in these explanations that the EOB will note if an adjustment has been made.
Answer: A statistical adjustment is a change to your claim that does not impact payments or dollars.
Answer: This will be noted on the E-EOB through the use of a Remark Code.
Answer: An upward adjustment is a change to the claim that results in a positive result for the subscriber or member on that particular claim. It may or may not impact payments or dollar amounts.
Answer: Upward adjustments will be noted on the E-EOB through the use of a Remark Code.
Answer: Select “Contact Us” or “Communication Center” in the top header of My Account to send a secure email to a CareFirst Customer Service Representative. You can also call the number on the back of your ID card to speak with a CareFirst Customer Service Representative.
Answer: You will be able to view Medical and Dental services.
Appeals and Complaints
Answer: An appeal is a timely request for a formal review of an adverse benefit decision, such as a claim denial or how we applied your deductible or co-insurance. An appeal may be submitted by you or your authorized representative.
Answer: A first-level appeal is the first formal internal review of the claim decision. Under most plans, first-level appeals must be filed within 180 days of the date you received your EOB. A second-level appeal is a second formal internal review of the claim decision.
Please check your health plan documents for the deadline to submit your appeal(s). On each level of appeal, a written response will be sent to you within the timeframe required by law. For plans that have two levels of appeal, a claim payment appeal is typically resolved within 30 days from the date we received your appeal request. There is a limit to the number of times you may appeal a decision. The limits are described in your plan documents, and the response will let you know if there are additional steps you can take. In the event you have exhausted your levels of appeal, the response you receive will notify you to that effect.