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Preferred Provider Organization (PPO/PPN) 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: 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.

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: CareFirst’s Preferred Provider Organization does not require prior approvals or referrals, but if you are referred by an in-network provider to an out-of-network provider, you will receive in-network benefits.

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Claims

How do I file a claim?

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

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 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. Please 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, you receive the highest level of benefits when you receive care for 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 of the adoption of your child 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 can only change your benefit plans once per year during your open enrollment period, unless you have a qualifying "life event." Life events include but are not limited to, births, deaths, adoption, marriage 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 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.

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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 move out of the area?

Answer: If you move out of the area, Preferred Provider Organization (PPO/PPN) 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 PPO/PPN 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 the ID Card.

What happens to my coverage if I turn 65?

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

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.

What happens to my coverage if I retire?

Answer: If you retire prior to age 65, you are eligible for the employer’s group coverage, if the employer desires. If you are age 65 or over, you are eligible for your employer’s Medicare supplemental insurance, if the employer desires.

What if I become disabled?

Answer: If you become permanently disabled, you may be eligible for Medicare.

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: Changes in family status allow you to adjust your coverage. You must notify your employer or CareFirst of the divorce within the time frame specified in your Evidence of Coverage booklet.

How can I find out if I have a particular benefit?

Answer: Your benefits are detailed in the Certificate of Coverage. You may also contact Member Services at 800-321-3497 to obtain specific information on contact benefits such as medical care, vision care, dental care, prescription benefits, etc.

Is my child covered while in college?

Answer: For coverage out of the area, Preferred Provider Organization (PPO/PPN) 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 PPO/PPN 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 member 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.

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

Answer: Your child living away at school is covered as long as he or she is a full-time student until the end of the calendar month in which he or she turns 25, unless otherwise stated in your Evidence of Coverage.

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.

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ID Cards

How do I order additional ID cards?

Answer: Additional ID cards can be ordered several ways.

What is my member ID card for?

Answer: Your card is important to getting the most out of your health plan. You will present your card when you receive care. Always carry your membership ID card with you.

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.

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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 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.

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

How do I get a provider directory?

Answer: The Preferred Provider Directory is available online or you may also call Member Services at the number on your member ID card and a representative can mail the directory to you.

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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.

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.

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.

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

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 is a primary care physician (PCP)?

Answer: Your PPO product does not require you to select a PCP. This doctor provides routine care and coordinates other specialized care. The PCP should be selected from the network that corresponds to the plan in which you are a member.

Can I go to an out-of-network provider?

Answer: Yes. If you need to go out-of-network for care, you may choose from over 20,000 health care providers across the region who participate with CareFirst BlueCross BlueShield. However, you must still meet any deductible and pay coinsurance. Your coinsurance may be higher because these providers are not in the network.

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

Answer: First, check to see if your physician participates with CareFirst BlueCross BlueShield. You may choose to get care from a physician who is not in the network. You must still meet a deductible and pay coinsurance, and your coinsurance may be higher because these providers are not in the Preferred Provider Network.

If your physician does not participate with CareFirst, you may be responsible for direct payment to the provider, as well as your deductible and coinsurance.

What if an in-network provider isn’t available to treat my condition?

Answer: If you need to go out-of-network for care, you may choose from over 20,000 health care providers across the region that participate with CareFirst BlueCross BlueShield. You must still meet any deductible and pay coinsurance. Your coinsurance may be higher because these providers are not in the Preferred Provider Network.

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.

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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.

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