CareFirst BlueCross BlueShield Is The Shared Business Name Of CareFirst .
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Chapter 4: Guidelines by Specialty/Service74
Institutional Ancillary ProvidersInformation on the following ancillary providers is contained in this section: Air Ambulance Ambulatory Surgical Centers (ASC) Dialysis Facilities Durable Medical Equipment (DME) Home Health Home Infusion Therapy (HIT) Hospice Skilled Nursing FacilitiesContract InformationIn order to be in-network for most of the CareFirst BlueCross BlueShield and CareFirst BlueChoice(CareFirst) memberships both locally and nationally, providers should hold two types of providercontracts: Regional Participating Preferred Network (RPN) BlueChoice NetworkClaims and Billing InformationUse the CareFirst self-service tools, CareFirst Direct and CareFirst on Call, to verify a member’s eligibility,benefits, authorization requirements and claim status. As a reminder, Third-Party Administrators (TPA)maintain all information on their members’ and should be contacted directly for eligibility, benefits, claimsstatus and payments.All claims should be submitted electronically. If a paper claim needs to be submitted, use the currentversion of the form for your provider type. All required fields must be completed, or the claim will berejected or returned: Current version of the CMS-1500 form (version 02/12) on original red-ink-on-white-paper. To ordera supply of forms, please use your normal process. Current version of the UB-04 form. Visit the National Uniform Billing Committee website to finddetails for using and ordering the new form.Providers are required to submit claims using standard code sets (e.g., CPT, HCPCS, ICD-10, revenuecodes, etc.). Please refer to the section below for your specific provider type for more detailedinformation and to your provider contract when submitting a claim. Where needed, please use modifiersappropriately.When needed, for more specific information, please refer to the CareFirst Medical Policies online.Please keep medical records current in the event additional documentation is requested to adjudicate theclaim. You will be contacted if this documentation is needed.Submit claims timely. Timely filing is 365 days from the date of service unless a member’s contract orhealth plan specifies differently.3
Air AmbulanceClaims and billing information For BlueCard members, refer to the BlueCard section of this manual for specific claims submissionrequirements. The following codes are required, as appropriate, when billing an air ambulance claim: A0430 A0431 A0435 A0436The appropriate modifier should also be included: HH: Hospital-to-hospital IH: Site of ambulance transport modes transfer to a hospitalTrip notes must be included with the claimFor additional information, please see the Ambulance Services Medical Policy (10.01.005) in the MedicalPolicy Reference Manual.Ambulatory Surgery CentersReimbursement—Attachments A-1 and A-2All covered Ambulatory Surgery Centers (ASCs) procedures that are reimbursable in an ASC setting areidentified in Attachment A-1 of the contract. Procedures not listed in Attachment A-1 are not eligible forreimbursement in an ASC setting.Multiple procedures performed on the same day will be reimbursed at the 100%, 50%/50% rule. Refer toyour contracts for exceptions.Inclusive supplies: All supplies are included in the allowed amount for the procedure except for specificitems listed on Attachment A-2 which are billed on the same claim and reimbursed separately.Prior authorizations and referrals for ASCsPrior authorization is not required for in-network freestanding ASCs for CareFirst members. Services arestill subject to benefit exclusions under the patient’s policy.Prior authorization may be required for: BlueCard members TPA members Self-insured accountsFor these types of plans, check the member’s benefits to determine if an authorization is required.Claims and billing information All extraordinary supplies, implants and high cost devices are billed by the ASC, not the DurableMedical Equipment (DME) supplier. Expense of high-cost devices, extraordinary supplies, implants and prosthetics are inclusive in thefacility fee unless otherwise noted in Attachment A-2.4
Extraordinary supplies used or implanted should be billed on individual lines with the appropriateHCPCS and/or CPT codes. Include the invoice for a corneal tissue implant. Refer to your provider contract for reimbursement rates: See Attachment A-1 for approved procedures See Attachment A-2 for supplies Must bill revenue code:490 for each procedure270, 274, 276, 278 for suppliesWhen Medicare is the primary payer, secondary claims must be submitted to CareFirst on a CMS1500 claim form.Dialysis FacilitiesContract informationThe CareFirst dialysis agreements will include Attachment A, Renal Dialysis and the related servicesreimbursement schedule that will list: Renal Dialysis and related services Payment rates UB-04 revenue codes Description of covered servicesNew dialysis therapy or the use of any medication will not be reimbursed until a formal written requestfor reimbursement is submitted to CareFirst. Please include the following information in your request: Supply clinical documentation and your proposed reimbursement rate with the request All written requests should be submitted to:CareFirst BlueCross BlueShield10455 Mill Run CircleP.O. Box 825Owings Mills, MD 21117-0825Mail Stop: CG-51ATTN: Institutional Contracting Manager—DialysisNote: CareFirst will respond within 45 days of receiving the written request.No authorization or referral is required if a CareFirst or FEP member uses an in-network dialysis facility.For those members who are out of state/BlueCard, providers should contact the member’s home planand ask if an authorization is required. Please call 800-676-BLUE.TPA Members should contact the TPA directly using the phone number on the back of the member’sidentification card.Claim and billing requirementsCertain revenue codes may be required (821, 841, 845, 851, 855).The drug dosage must match what is in the contract.5
Durable Medical EquipmentContract informationPlease refer to the DME Medical Policies in the Medical Policy Reference Manual, which identify: Definitions of DME Excluded items Medical policy guidelines Medical necessityClaims and billing requirementsPlease note that prior authorization for DME should be entered through the Provider Portal. Keepmedical records current in case you need to include any of the following when you submit a claim: Letter of medical necessity Certificate of medical necessity PrescriptionsHome HealthClaims and billing requirementsPlease note that prior authorization for home health services should be entered through the providerportal.Please refer to your provider contract for any required revenue codes: 421 431 441 551 561 571Please keep the following reminder in mind when submitting your claims: All rates are inclusive of routine supplies Supplies pay per the terms of the Participation Agreement. A list of eligible Non Routine Supplies can be found here.Home Infusion TherapyClaims and billing requirementsPlease refer to Attachment A and Schedule A & B for specific code requirements. Please keep thefollowing reminders in mind when submitting your claims: CareFirst has one HIT policy and processing guidelines for all lines of business. Submit claims electronically using HIPAA 837P.6
If you do not have electronic capabilities, paper claims must be submitted using the currentversion of CMS-1500 or they will be rejected. Claims must be submitted with the provider’s NPI. Do not submit attachments with claims. Please bill claims by year. The same claim cannot span multiple years. Medicare Explanation of Medical Benefits (EOMB) is waived for 99601 and 99602.Home infusion therapy claims Home infusion therapy claims are billed with: Per Diem code (S codes) In-home nursing code (99601 & 99602) Drug codes (J, S, P, Q, and B codes) Modifiers for multiple therapies (SH - second concurrent therapy and SJ – third or moreconcurrent therapy)In-home nursing for FEP Limit of 2 hours per day, up to 25 visits per calendar year (99601) Additional nursing (99602) will not be allowed or reimbursed. Please see the member’s benefitbooklet for more information. Please confirm that copays/coinsurance are applicable.Drug volume CareFirst does not reimburse for the amount of drugs used for priming or residual use. Overfill/overflow is not covered. Reimbursement is based on the dosage prescribed, not the concentration ordered.Renal failure/dialysis When a patient is receiving dialysis, the HIT provider is unable to bill for infusion of drugs (e.g.,EPOGEN ) or other related ancillary services.Stock suppliesIn the event of discontinuation of therapy, cancellation of orders, change in medication, readmission to afacility or in the event of death, CareFirst will reimburse for 72 hours of drugs or Total ParenteralNutrition stock supply. Clear documentation should be kept in the patient’s service record.Utilization of drug code J3490 This code can be utilized when no other HCPCS are available for a specific drug. The corresponding National Drug Code number must be included.Documentation required in the patient’s file Signed and dated Plan of Treatment/Certificate of Medical Necessity or physicians’ orders must becurrent7
Nursing assessment Nursing notes, documentation on additional nursing services beyond the contract limitationsNote: All treatment plans, certificates of medical necessity or physicians’ orders must be updated yearlyItems not covered Oral medications Subcutaneous injections Please bill through the patient’s pharmacy benefit. Growth Hormone Synagis Hormonal TherapyWritten requestsWritten requests for any new or non-listed therapies should be submitted to Pharmacy Management:Attn: Manager Home Infusion TherapyCareFirst BlueCross BlueShield1501 S. Clinton St.Mail Stop CantonBaltimore, MD 21224HospiceClaims and billing requirementsSubmit claims, services and revenue codes contained in your contract. Only request prior authorizationsfor the revenue codes contained in your contract. Inpatient Hospice Compensation Schedule: Revenue codes 656, 655Home Hospice Compensation Schedule: Revenue codes 651, 652Additional reminders DME and infusion medications must be approved by care management and billed by the providersupplying these items If a hospice “rents” space in a Skilled Nursing Facility (SNF), a long-term care facility or hospital, thehospice must bill for hospice services. Hospice facilities will use the same RPN provider number for all services (home hospice andinpatient hospice). For FEP members, refer to the FEP benefit plan information. Submit claims with the corresponding dates included with your prior authorization request. Providers are required to submit standard code sets (CPT, ICD-10, HCPCS).8
Authorization processPrior Authorizations may be required for both inpatient and outpatient services for: CareFirst members BlueCard members TPA members Self-insured accountsBe sure to check the member’s benefits to determine if an authorization is required.For inpatient authorizations contact the appropriate area for assistance:Authorization ContactsMember typePhone numberCareFirst memberInpatient hospice866-PRE-AUTH, option 1(866-773-2884)FEP member800-360-7654, Care ManagementBlueCard memberContact home plan800-676-BLUE(800-676-2583)Self-Insured member877-228-7268TPA memberContact the member’s TPA at the phone number on the back of themember identifications card for instructions or refer to the numberon the TPA prefix listing.Skilled Nursing FacilitiesCheck a member’s benefits to determine if a prior authorization is required. Please contact theappropriate authorization area using the phone numbers below.Authorization ContactsMember typePhone numberCareFirst member—admittedfrom inpatient setting866-PRE-AUTH, option 1(866-773-2884)9
Authorization ContactsCareFirst member—admittedfrom home or community1-866-Pre-Auth, Option 11-866-773-2884Case Management1-800-443-5434, Option 5FEP member800-360-7654, Care ManagementBlueCard memberContact home plan800-676-BLUE(800-676-2583)Self-Insured member877-228-7268TPA memberContact the member’s TPA at the phone number on the back of themember ID card for instructions or refer to the number on the TPAprefix listing.When there is a need for a member to be admitted into a Post-Acute Facility (SNF, Acute Rehab, LongTerm Acute Care, Hospice) from an inpatient facility, CareFirst’s Hospital Transition Coordinators (HTC’s)are available to assist with the member’s care coordination. The discharge planner works with the PostAcute Facility, the member/member’s family and the CareFirst HTC to determine the appropriate level ofcare for the member. The HTC will provide an admission decision within 24 hours of the request fortransfer. The authorization is given to the facility within 24 hours of verification of the admission.When there is a need for a member that is out of CareFirst’s service area (outside of Maryland, D.C., orNorthern Virginia) to transfer into a Post-Acute Facility, the facility must complete and fax the Post-AcuteTransition of Care Authorization form to the Transition of Care Team at 410-505-2588.CareFirst will verify the member’s benefits, and the HTC assigned to the admitting Post-Acute Facility willprovide an admission decision and authorization within 24 hours of the request for transfer. The assignedHTC will also be responsible for continued stay review and decision.Claims and billing requirements Providers are required to submit claims using standard code sets (e.g., CPT, ICD-10, HCPCS). Refer to your provider contract for more information. Certain revenue codes may be required (e.g.,191, 192, 193, 194). FEP case managed claims need to be sent with the care management letter to the address listed onthe letter.10
Professional Services, Tips and RemindersPrimary CareThe Patient-Centered Medical Home (PCMH) Program is designed to provide primarycare providers (PCPs) with a more complete view of their patients’ needs. PCMH guidesmembers to establish a relationship with their PCP to receive consistent quality care. Using PCPs as a firstcontact or “home base” for most medical and behavioral needs ensures members get the care they need,when they need it, leading to improved health, increased communication and better outcomes.To aid in this communication and relationship, providers are given exclusive access to resources likeelectronic medical records and a large network of specialized clinicians. Behavioral health clinicians andRegistered Nurses help providers better coordinate their member’s overall health and assist in navigatingthe complex healthcare landscape.The PCMH Program requires greater provider engagement and CareFirst meaningfully compensatesproviders for that engagement. PCMH is structured around PCPs organized into teams called Panels—groups of five to 15 physicians—for purposes of coordinating the care of CareFirst members to improvehealthcare outcomes and reduce the global cost of care. As care-giving teams, Panels have theopportunity to earn robust financial incentives—a 12% participation fee increase and a reimbursementfor Care Coordination. In addition, Panels can earn Outcome Incentive Awards that are paid as increasesto their fee schedules based on both the level of quality and degree of savings they achieve againstprojected costs each year.For more information on how to join and be successful in the PCMH Program, view our Adult andPediatric program description and guidelines or visit carefirst.com/pcmhinfo.Helpful Information for SpecialistsSpecialty typeMedical society resourcesKey medicalpoliciesGastroenterologyAmerican College ofGastroenterologyScreening forcolorectal cancer –2.03.011A ColorectalcancerscreeningSurgery – 7.01 Optimaldiabetes care Hypertension All causereadmission EmergencydepartmentutilizationSociety of AmericanGastrointestinal and EndoscopyAmerican essData andInformation Set(HEDIS) focusObesity – 7.01.036Transplants 7.0311
Specialty typeMedical society resourcesKey medicalpoliciesGeneral SurgeryAmerican College of SurgeonsSurgery – 7.01 Surgical Assistants –10.01.008ASmokingCessation OptimalDiabetes Care Hypertension All causereadmission yAmerican Gynecological &Obstetrical SocietyGlobal MaternityCare – 4.01.006A Breast cancerscreeningAmerican College ofObstetricians andGynecologistsPreventive services –10.01.003A Cervix cancerscreeningGlobal surgical carerules – 10.01.009A Early electivedeliversMultifetal pregnancyreduction –4.02.003A Prenatal andpostpartum Optimaldiabetes care Hypertension All causereadmission Use of imagingfor lower backpainPreimplantationgenetic testing –4.02.007Lactationconsultations –4.01.010Orthopedic SurgeonsHealthcareEffectivenessData andInformation Set(HEDIS) focusAcademy of OrthopedicSurgeonsDurable medicalequipment – 1.0American Orthopedic Societyfor Sports MedicineMedical Equipment –1.01 Medical supplies –1.02Optimaldiabetes care Hypertension All causereadmission12
Specialty typeMedical society resourcesKey medicalpoliciesOrthotic devices andorthopedicappliances – 1.03HealthcareEffectivenessData andInformation Set(HEDIS) focus EmergencydepartmentutilizationProsthetics – 1.04Surgery – 7.01Rehabilitationtherapy – 8.00Physical/occupational/speech therapy –8.01Other Specialty ServicesMedication: Office Injectable DrugsMedications administered in the provider’s office are covered under the member’smedical benefit, not their prescription drug benefit. Prescription drug benefits coverinjectable medications only when they are self-administered.Note: Depo-Provera (when used for contraception) is the only non-self-administered injectable coveredunder the prescription drug benefit.Providers will need to obtain office administered injectable medications and bill CareFirst directly.Members may not fill a prescription and then deliver it to the provider. These medications are notcovered by the member’s prescription drug benefit.For commercial members, providers may obtain injectable medications from a source of their choice.CareFirst has a contract with CVS Caremark . CVS Caremark can ship single dose of most injectablemedications, on an individual patient (prescription) basis, directly to the provider office for administering.This option is available for most office injectables, eliminating the upfront cost of stocking expensivespecialty injectables. CVS Caremark will obtain eligibility and benefits, then bill CareFirst directly. Yourpractice should continue to bill CareFirst for the administration by following current proceduralterminology (CPT ) guidelines and using the appropriate CPT codes.Orders for non-refrigerated, refrigerated and frozen medications and vaccines are packed intemperature-controlled containers and shipped directly to your office, typically within 48 hours. Priorityovernight delivery is also available. This is an optional service we make available and is not a guarantee ofavailability or supply by CareFirst. Not all drugs or individual prescriptions are available using this option.Note: The arrangement with CVS Caremark does not apply to members whose primary coverage isMedicare.13
Standard reimbursement methodologyIf you obtain office injectable drugs, the following standard reimbursement methodology applies.Injectable drugs are reimbursed at 6% above the average sales price (ASP). Injectable drugs without anASP may be reimbursed at 20% off the lowest average wholesale price (AWP). The ASP is calculated by theCenters for Medicare and Medicaid Services (CMS) and is available at CMS.gov. The AWP is sourced from athird party and is reflective of data comprised from multiple nationally recognized pricing services,including pharmaceutical manufacturers.Standard reimbursement for all in-office injectable drugs is updated quarterly on the first of February,May, August and November. These updates reflect the industry changes to ASP or AWP. If there aredelays in industry changes for certain seasonal injectable drugs (e.g., flu), then standard reimbursementsmay be updated on the first day of the next month. The specific reimbursement arrangements forparticipants in the CareFirst oncology program are not impacted by the above changes to standardreimbursement.Exemptions to standard pricing methodologyExemptions to standard pricing methodology include: Pediatric vaccines are reimbursed at 100% of AWP. Select vaccines are reimbursed at AWP-15%.Medical InjectablesCertain high-cost medical injectables therapy drugs require prior authorization when administered in anoutpatient hospital and home or office settings.Intravenous immune globulin (IVIG) and select infusions can be administered in the outpatient hospitalsetting only if medical necessity criteria are met at the time of prior authorization. Information on allmedications that require prior authorization and are part of the Site of Care program, including thesetherapy drugs is available at carefirst.com/preauth Medications.Prior authorizations should be submitted online at carefirst.com/providerlogin. Click on the PreAuth/Notifications tab to begin your request. Failure to obtain a prior authorization for these medicationsmay result in a denial of the claim payment.For questions related to a prior authorization that was submitted for these medications, please call CVSCaremark at 888-877-0518.CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland,Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Crossand Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is thebusiness name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross and Blue Shield and the Cross and Shield Symbols are registered servicemarks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.All other trademarks are property of their respective owners.14
The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.).
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare . receives an individual member ID card with the name of the PGD on the card. . covering dentist, or off
Consumer Health Insurance Plans 2021—Northern Virginia 1. Welcome. Thank you for considering CareFirst BlueCross . BlueShield and CareFirst BlueChoice, Inc. (CareFirst)
Consumer Health Insurance Plans 2020—Northern Virginia 1. Welcome. Thank you for considering CareFirst BlueCross . BlueShield and CareFirst BlueChoice, Inc. (CareFirst) for your health care coverage. As the largest health care insurer in the Mid-Atlantic region, we know how much you and your family depend on us for your health coverage.
2022 SUMMARY OF BENEFITS January 1, 2022 - December 31, 2022 Medicare Blue Choice . (H3351-011) This is a summary of drug and health services covered by Excellus BlueCross BlueShield. Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield .
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
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Members from other Blue Cross and Blue Shield HMOs can enroll in CareFirst BlueChoice, select a PCP and receive a standard ID card. Benefts may vary; it is important to contact Provider Services at 800‑842‑5975 or visit . CareFirst Direct to verify coverage in the state. This program does not change CareFirst BlueChoice providers' normal .
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