• Print:
  • Text Size:

Have a Question, But Can’t Find the Answer Here?

Ask A Question

Maryland POS Frequently Asked Questions

Expand All | Collapse All

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: You may call Member Services at the number on your member ID card. In many instances, the matter can be resolved quickly through informal discussions and information gathering.

If your concern is not resolved through a discussion with a CareFirst representative, you or someone on your behalf may make a formal request for reconsideration. The request must be received by CareFirst within 6 months of the date of denial of benefits or services.
 
You may request a review by the Grievance and Appeal Committee if you are still not satisfied with the response resulting from a request for reconsideration. Your request must be in writing, addressed to our Grievance and Appeal Committee and state the reason for the request. You or someone on your behalf must make the request within 60 days from the date of the reconsideration determination.

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

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)
  • The health care services are necessary to treat a condition or illness that, without immediate medical attention, would seriously jeopardize your life or health, 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.

Expand All | Collapse All

Expand All | Collapse All

Approvals and Referrals

What services require prior approval or a referral?

Answer: Some specialty services require prior approval or a referral from your PCP. You may choose to see a specialist without a referral from your PCP, however you will pay a greater share of the cost.

Please note that the Maryland Point of Service Provider Directory may list specialists, such as chiropractors, whose services are not included within your particular benefits plan.

How do I get prior approval or a referral?

Answer: Your Primary Care Physician (PCP) coordinates your in-network care. When you need specialty care, your PCP will refer you to a specialist within the Maryland Point of Service network for the highest level of benefits.

Please note that the Maryland Point of Service Provider Directory may list specialists, such as chiropractors, whose services are not included within your particular benefits plan.

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

Answer: If you do not obtain prior approval or a referral from your PCP, or you choose a specialist that does not participate in the Maryland Point of Service network, benefits for covered services will be considered at the out-of-network level. You will pay a greater share of the cost.

When do I need a referral from my PCP?

Answer: You may need a referral from your PCP when you are seeking specialty services. You may choose to see a specialist without a referral from your PCP; however, you will pay a greater share of the cost. You do not, however, need a referral from your PCP when visiting an in-network OB/GYN.

Please note that the Maryland Point of Service Provider Directory may list specialists, such as chiropractors, whose services are not included within your particular benefits plan.

Expand All | Collapse All

Expand All | Collapse All

Claims

How do I file a claim?

Answer: An advantage of Maryland Point of Service (MPOS) coverage is that you do not have to file any claims when you visit your PCP or any other CareFirst provider. MPOS providers are required to submit claims for reimbursement and all you have to do is pay any necessary copayment at the time of your visit.

If you do need to submit a claim for care received by a provider outside of the MPOS or CareFirst network, you may contact Member Services at the number on your member ID card for a MPOS claim form or, find one on our Forms page.

How long do I have to file a claim?

Answer: The time allowed to file a claim varies depending on your contract. Please call Member Services at the phone number on your member ID card for specific guidelines.

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

Answer: A preferred provider will not bill the member for the difference in CareFirst’s payment and the member’s required deductible, coinsurance and copayments. Preferred providers accept CareFirst’s allowed benefit as payment in full. If you are unsure as to whether you should pay a bill, please call Member Services at the phone number on your ID card.

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 payments have reached the limit on how much you have to pay for covered medical care in a calendar year, the plan pays 100% of the allowed benefit of your eligible expenses for the rest of that calendar year.

What is Coordination of Benefits (COB)?

Answer: Coordination of Benefits (COB) applies when a member has health insurance under more than one plan. COB rules determine which of the two plans’ coverage applies.

Why did I receive a Coordination of Benefits 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. Please return this form in order to prevent any delays in processing claims.

Expand All | Collapse All

Expand All | Collapse All

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, you receive the highest level of benefits when you receive care for emergencies or accidental injuries.

Expand All | Collapse All

Expand All | Collapse All

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 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.

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

Answer: Yes, provided your employer provides coverage for over-age dependents. Covered dependents enrolled in a college that is located outside of the CareFirst service area are eligible for benefits. However, most covered services will be paid at the out-of-network level because the primary care physician (PCP) will not be coordinating his/her care.

How do I obtain coverage for my newly adopted child?

Answer: Changes in family status allow you to adjust the level of your coverage. To obtain immediate coverage, you must notify your employer or CareFirst of the adoption of your child within the timeframe specified in your Evidence of Coverage booklet. Please refer to your Evidence of Coverage booklet for more details.

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

Answer: As long as your child was covered before reaching the plan’s limiting age (for example, age 19 or 23 if a full-time college student), coverage continues for as long as you are covered under the plan. Please refer to your Evidence of Coverage booklet.

Expand All | Collapse All

Expand All | Collapse All

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.

Is my child covered while attending an out-of-state college?

Answer: Higher levels of benefits are available for covered services given by in-network practitioners that participate with another Blue Cross and Blue Shield (BCBS) 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 and/or preferred providers. Benefits are also available for covered services given by practitioners that do not participate with a BCBS plan. However, you will be financially responsible for balances over the allowed benefit and you may have to file your own claims.

When your child needs care, simply show your member ID card and the hospital or doctor can submit the claims. However, if payment is required up-front, contact Member Services to obtain a claim form for consideration and reimbursement of charges.

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 my spouse and I divorce?

Answer: Please contact your employer to learn if your spouse has the option to continue coverage. This coverage would occur at your own expense through the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Refer to your Evidence of Coverage booklet for more details.

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: Your coverage continues but at the out-of-network level because your Primary Care Physician (PCP) is no longer coordinating your care.

Also, MPOS allows you to use the BlueCard® program. Through the BlueCard®  program, you may select from national Blue Cross and Blue Shield BlueCard®  participating providers. The BlueCard® providers have agreements to accept our payments (after the member’s coinsurance and deductible) as payment in full. Benefits will be given at the out-of-network level since your PCP is not coordinating your care.

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

Is my child covered while in college?

Answer: Yes, provided your employer provides coverage for over-age dependents. Covered dependents enrolled in a college located outside of the CareFirst service area are eligible for benefits. However, most covered services will be paid at the out-of-network level because the Primary Care Physician (PCP) will not be coordinating his/her care.

Also, Maryland Point of Service (MPOS) allows you to use the BlueCard®  program. Through the BlueCard®  program, you may select from national Blue Cross Blue Shield BlueCard®  participating providers. The BlueCard® providers have agreements to accept our payment (after the member’s coinsurance and deductible) as payment in full. Benefits will be given at the out-of-network level since your PCP is not coordinating your care.

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

Do I have coverage for pre-existing conditions?

Answer: Generally, yes; however, some employers include a pre-existing condition limitation that can be up to 12 months. As long as there has not been a lapse of coverage for more than 63 days, credit for prior coverage is given that will reduce the pre-existing condition limitation.

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.

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.

Expand All | Collapse All

Expand All | Collapse All

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: Yes, always carry your ID card with you and present it wherever you receive care. Our Member Services telephone number is on your card. The back of the card lists other important telephone numbers to help you in accessing care.

Expand All | Collapse All

Expand All | Collapse All

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.

Expand All | Collapse All

Expand All | Collapse All

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 listed on your ID card to obtain specific information regarding coverage.

How do I change my name or address?

Answer: Call a Member Services Representative at the number on your member ID card to change your name or address.

How do I get a provider directory?

Answer: The Point of Service PCP and Specialist Provider Directories are available online or you can call Member Services at the number on your member ID card and a representative can mail the PCP directory to you.

What are your Member Services hours?

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

How and when can I contact the health plan?

Answer: You may contact the health plan by phone Monday through Friday, 7 a.m. to 7 p.m., EST, by calling the phone number on the front of your ID card. You may also send written correspondence to:

CareFirst BlueCross BlueShield
Member Services
10455 Mill Run Circle
Owings Mills, MD 21117-5559

Expand All | Collapse All

Expand All | Collapse All

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.

Expand All | Collapse All

Expand All | Collapse All

Physicians and Other Providers

How do I find a network provider?

Answer: The Maryland Point of Service (MPOS) program uses CareFirst’s Maryland Point of Service Provider Directory. To determine if a provider is a MPOS Participating Provider, or to locate a participating physician in your area, you may search our online provider directory, the most up-to-date provider listing available or call Member Services at the number listed on your member ID card and a representative can mail you a 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 MPOS 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: You receive the highest level of benefits and you have no claims to file when you visit a network provider.

Can I change my PCP any time I want?

Answer: Yes. You can change your PCP by going online or by calling a Member Services Representative at the number listed on your member ID card.

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

Answer: You can change your PCP by calling a Member Services Representative at the number listed on your member ID card or online.

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

Answer: You will need to select another PCP. 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.

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

Answer: 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 (severe) problem, most offices try to schedule you within 24-72 hours or less, depending on the urgency of the problem.

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

Answer: You may choose to go outside the network for care, but you will pay higher out-of-pocket costs and must meet an annual deductible for out-of-network care. A non-network provider may require you to file your own claims and may bill you for the difference between our allowed benefit and their charge for services.

Can I go to a non-network provider?

Answer: You may choose to go out-of-network for care, but you will pay more out-of-pocket expenses and must meet an annual deductible for out-of-network care. A non-network provider may not file claims for you and may bill you for the difference between our allowed benefit and their charge for services.

Expand All | Collapse All

Expand All | Collapse All

Travel Coverage

What do I do if I need care while traveling?

Answer: Benefits are available for covered services given by network practitioners that participate with another Blue Cross and Blue Shield (BSBS) plan. The BlueCard® program puts you in touch with these local network providers. Call BlueCard Access at 1-800-810-BLUE or visit the BlueCard Web site for a list of participating providers.

Benefits are covered for services rendered by practitioners that do not participate with a BCBS plan. However, you may be financially responsible for balances over the allowed benefit.

When you need care, simply show your member ID card and the hospital or doctor can submit the claims. However, if payment is required up-front, contact Member Services to obtain a claim form for consideration and reimbursement of charges.

What emergency coverage do I have while I am traveling?

Answer: You will receive the highest level of benefits for emergency care.

Expand All | Collapse All