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Provider Manual
The following information is for our Provider Community.
To quickly access the information you need, click and print the individual section PDF. You can also download and print the complete manual.
Chapter 1: Welcome to CareFirst
| Chapter 1: Welcome to CareFirst | |
| Introduction to CareFirst | |
| Online Resources & Contact Information | |
| Introduction to the Manual | |
| How to Use this Manual | |
| New Providers/Office Staff Begin Here |
Chapter 2: Product Descriptions
| Chapter 2: Product Descriptions | |
| Overview | |
| BlueChoice Products | |
| Preferred Provider Organization (PPO) | |
| Exclusive Provider Organization (EPO) | |
| HealthyBlue | |
| Federal Employees Health Benefit Plan/Federal Employee Program | |
| BlueCard Program | |
| Network Lease/Third Party Administrators |
Chapter 3: Provider Network Requirements: Administrative Functions
| Chapter 3: Provider Network Requirements: Administrative Functions | |
| Credentialing | |
| Practice Transformation | |
| Provider Scorecard | |
| Role of the Primary Care Provider (PCP) – BlueChoice Only | |
| Reduction, Suspension or Termination of Privileges | |
| Quality of Care Termination | |
| All Other Sanctions or Terminations | |
| Member to be Held Harmless | |
| Reimbursement | |
| Reimbursement for Limited Licensed Providers | |
| Physician Assistants, Anesthesia Assistants, Assistant Behavioral Analysts and Registered Behavior Technicians | |
| Concierge Services Policy | |
| Confidentiality | |
| Administrative Services Policy | |
| Treatment of Family Members or Self | |
| Member Complaints | |
| Requests for Charts | |
| Advance Directives |
Chapter 4: Guidelines by Specialty/Service
| Chapter 4: Guidelines by Specialty/Service | |
| Institutional Ancillary Providers | |
| Professional Services, Tips and Reminders |
Chapter 5: Claims, Billing and Payments
| Chapter 5: Claims, Billing and Payments | |
| Introduction to Claims Submission | |
| Provider Self Service | |
| Use of Third-Party Billing Companies | |
| Basic Claim Submission Requirements | |
| Guidelines for Ancillary Claims Filing | |
| Special Claims Submission Information for Facility Billing | |
| Timely Filing of Claims | |
| Electronic Capabilities | |
| Paper Claims Submission Process | |
| Medicare Crossover Claims Submission | |
| How to Submit Claims with Denied Charges | |
| Notice of Payment | |
| Claims Overpayments | |
| Collection of Retroactively Denied Claims | |
| Effective Follow-Up on Claims | |
| Corrected Claims, Inquiries and Appeals | |
| Coordination with Other Payers/Other Party Liability |
Chapter 6: Fraud, Waste, and Abuse
| Chapter 6: Fraud, Waste, and Abuse | |
| Special Investigations Unit | |
| Payment Integrity Program |
Chapter 7: Care Management
| Chapter 7: Care Management | |
| Quality Improvement (QI) Program | |
| Clinical Guidelines | |
| Performance Data | |
| Population Assessments | |
| Maintaining the Access, Availability and Quality of Our Network Providers and Hospitals | |
| Population Health and Social Determinants of Health | |
| Population Health Management and the Patient-Centered Medical Home and Clinical Program Model | |
| National Committee for Quality Assurance | |
| Complaint Process | |
| Language Assistance | |
| Disease Management Programs | |
| Clinical Programs | |
| Clinical Resources | |
| Outpatient Pre-Treatment Authorization Plan (OPAP) | |
| Coordinated Home Care and Home Hospice Care | |
| Hospital Transition of Care (HTC) | |
| Comprehensive Medication Review (CMR) Program | |
| Behavioral Health and Substance Use Disorder (BSD) Program | |
| Gender Services | |
| Inpatient Hospitalization Services | |
| Prior Authorizations and Notifications | |
| Complex Case Management |
Chapter 8: BlueChoice: Health Maintenance Organization
| Chapter 8: BlueChoice: Health Maintenance Organization | |
| Arranging for Care | |
| Laboratory Services | |
| Specialist | |
| Authorization | |
| Medical Injectables | |
| Emergency Room Services | |
| Emergency Hospital Admissions | |
| Hospital Services | |
| Benefit Exclusions and Limitations |
Chapter 9: Policies and Procedures
| Chapter 9: Policies and Procedures | |
| Medical Policy and Technology Assessment | |
| Claims Adjudication Edits | |
| Place of Service Code Assignments | |
| Basic Claim Adjudication Policy Concepts | |
| Global Surgical, Anesthesia and Maternity Reimbursement Guidelines | |
| Multiple Surgical and Diagnostic Procedures Reimbursement Guidelines | |
| Multiple Provider Participation in Surgical Procedures | |
| General and Specialty-Related Claim Adjudication Policies and Reimbursement Guidelines | |
| Surgery/Orthopedics | |
| Medicine/Oncology | |
| Genito-Urinary | |
| Pediatrics/Neonatology | |
| Obstetrics & Gynecology | |
| Radiology/Imaging | |
| Invasive and Non-Invasive Diagnostic Tests and Procedures |
Chapter 10: Medicare Advantage
| Chapter 10: Medicare Advantage | |
| Medicare Advantage Overview | |
| CareFirst MA Product Offerings | |
| Provider Networks | |
| Provider Network Participation | |
| Role of Primary Care Physician | |
| Claims Submission | |
| Billing and Payment | |
| Appeals and Grievances | |
| Quality Improvement | |
| Practice Transformation | |
| Medicare Pharmacy Management | |
| Preservice Review & Compliance/Utilization Management | |
| Clinical Programs for Medicare Advantage Members |