[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-664356-105":59,"doc-detail-664356-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","carefirst-administrative-functions-professional-provider-manual","CareFirst Administrative Functions - Professional Provider Manual","","Administrative Functions section for CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (together, CareFirst) patients outlines provider participation requirements under the Participation Agreement and explains how procedural updates are communicated via email and BlueLink. The document details member eligibility, benefits, and claims information access through CareFirst Direct or the Voice Response Unit, and introduces the credentialing workflow, verification criteria, provider rights to review/correct information, and practice information verification twice per year. It also covers CAQH ProView application steps and network participation alignment.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/carefirst-administrative-functions-professional-provider-manual/664356/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/carefirst-administrative-functions-professional-provider-manual/664356.png","ImageObject",300,407,{"name":92,"@type":93},"Helloiii","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-10-29",true,{"@type":102,"interactionType":103,"userInteractionCount":81},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Providers must follow which requirements when participating in CareFirst networks?","Question",{"text":112,"@type":113},"Providers must adhere to the policies and procedures required under the Participation Agreement, as applicable.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How can members and providers get questions answered about eligibility, benefits, or claims status?",{"text":117,"@type":113},"Use self-service channels such as CareFirst Direct or the Voice Response Unit for quick responses to simple questions.",{"name":119,"@type":110,"acceptedAnswer":120},"What are the main steps and expectations in the CareFirst credentialing process?",{"text":121,"@type":113},"Providers submit credentialing information, it is verified against credentialing criteria, and CareFirst may use CAQH ProView to receive application data electronically and begin credentialing after authorization and completion.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},664356,1793252567,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":81,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":129,"read_time":144},5909897196768,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","This section provides Administrative Functions information for your CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.(collectively CareFirst), patients.  \nPer the terms of the Participation Agreement, all providers are required to adhere to all policies and procedures, as applicable.  \nIf we make any procedural changes in our ongoing efforts to improve our service to you, we will update the information in this section and notify you through email and BlueLink, our online provider newsletter.  \nSpecific requirements of a member’s health benefits vary and may differ from the general procedures outlined in this manual. If you have questions regarding a member’s eligibility, benefits, or claims status information, we encourage you to use one of our self‑service channels; CareFirst Direct or the Voice Response Unit. Through these channels, simple questions can be answered quickly.  \nRead and print the Guidelines for Provider Self‑Services.  \nAdministrative Functions  \nMedical Credentialing  \nProviders wishing to participate in the CareFirst provider networks are required to submit credentialing information. This information is verified to confirm that our credentialing criteria is met. This includes, but is not limited to:  \nn  \nn  \nn  \nn  \nn  \nn  \nn  \nn  \nn  \nn  \nValid, current, unrestricted licensure  \nValid, current Drug Enforcement Agency (DEA) and Controlled Dangerous Substance (CDS) registration Appropriate education and training in a relevant field  \nBoard certification, if applicable  \nReview of work history  \nActive, unrestricted admitting privileges at a participating network hospital  \nAcceptable history of professional liability claims Acceptable history of previous or current state sanctions, Medicare/Medicaid sanctions, restrictions on licensure, hospital privileges and/ or limitations on scope of practice  \nAttestation to reasons for an inability to perform the essential functions of a clinical practitioner that could impose significant health and safety risks to members/enrollees; lack of present illegal drug use; history of loss of license and felony convictions; history of loss or limitation of privileges or disciplinary action  \nCurrent malpractice insurance coverage with minimum limits as indicated on the next page:  \nCareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc . and Group Hospitalization and Medical Services, Inc . CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc . are both independent licensees of the Blue Cross and Blue Shield Association.® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc .  \nPM0007‑1E (9/16)  \nPROFESSIONAL | PROVIDER MANUAL  \nCONTENTS   \nLAST VIEWED   \n>  \n\u003C  \n| Number of Practitioners in Practice\u003Cbr>1 | Medical Practices Primary Layer\u003Cbr>$1/$3M Individual | Medical Practices Excess Layer\u003Cbr>N/A | Mid‑Level\u003Cbr>Behavioral Primary Layer $.5/$1.5M Individual | Mid‑Level Behavioral Excess Layer\u003Cbr>N/A | PT/OT/ST Primary Layer Only\u003Cbr>$1/$3M Shared (up to 24) |\n| --- | --- | --- | --- | --- | --- |\n| 2–5 | $1/$3M Shared | N/A | $.5/$1.5M Shared | N/A | $1/$3M Shared (up to 24) |\n| 6–10 | $2/$6M Shared | N/A | $1/$3M Shared | N/A | $1/$3M Shared (up to 24) |\n| 11–24 | $2/$6M Shared\u003Cbr>$1/$3M Shared | $5M Shared\u003Cbr>$10M Shared | $1/$3M Shared $.5/$1.5M Shared | $3.25M Shared\u003Cbr>$7.5M Shared | $1/$3M Shared (up to 24) |\n| 25–50 | $2/$6M Shared\u003Cbr>$1/$3M Shared | $10M Shared\u003Cbr>$15M Shared | $1/$3M Shared $.5/$1.5M Shared | $5M Shared\u003Cbr>$10M Shared | Individual Consideration |\n| 51+ | Individual Consideration | Individual Consideration | Individual Consideration | Individual Consideration | Individual Consideration |\n\nTo make sure that CareFirst has obtained correct information to support credentialing applications and made fair credentialing decisions, providers have the right, upon request, to review this information, to correct inaccurate information and to","cbCaisp8GpmdpJ3t","https://ap.wps.com/l/cbCaisp8GpmdpJ3t","pdf",849389,14,"English","# Administrative Functions\n## Medical Credentialing\n## Provider Self-Services and Information Access\n## Guidelines and Provider Information Verification","[{\"question\":\"Providers must follow which requirements when participating in CareFirst networks?\",\"answer\":\"Providers must adhere to the policies and procedures required under the Participation Agreement, as applicable.\"},{\"question\":\"How can members and providers get questions answered about eligibility, benefits, or claims status?\",\"answer\":\"Use self-service channels such as CareFirst Direct or the Voice Response Unit for quick responses to simple questions.\"},{\"question\":\"What are the main steps and expectations in the CareFirst credentialing process?\",\"answer\":\"Providers submit credentialing information, it is verified against credentialing criteria, and CareFirst may use CAQH ProView to receive application data electronically and begin credentialing after authorization and completion.\"}]","CareFirst Administrative Functions - Professional Provider Manual | PDF",35]