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The manual consolidates administrative and clinical processes including medical credentialing, role of the primary care provider, referrals, electronic claims, timely filing, reconsiderations, appeals, and member complaint handling. It also covers reimbursement methodologies, HIPAA-compliant coding guidance, care management programs, utilization control, authorization and referrals, confidentiality, privacy notices, and key claim adjudication policy concepts.",{"@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/provider-manual-carefirst-provider-community-2019-provider-guide/640715/",{"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/provider-manual-carefirst-provider-community-2019-provider-guide/640715.png","ImageObject",300,407,{"name":92,"@type":93},"Ophelia","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-01","2026-10-22",true,{"@type":102,"interactionType":103,"userInteractionCount":39},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What are providers required to follow in the CareFirst Participation Agreement?","Question",{"text":112,"@type":113},"Providers must adhere to applicable policies and procedures contained in the manual, as required by the Participation Agreement.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How are provider and member questions handled regarding eligibility, benefits, or claim status?",{"text":117,"@type":113},"The manual directs providers to use CareFirst self-service channels (including CareFirst on Call and CareFirst Director), which can answer simple questions quickly.",{"name":119,"@type":110,"acceptedAnswer":120},"Which parts of the manual cover claims handling and disputes?",{"text":121,"@type":113},"Claims processing sections include submission processes, timely filing, reconsideration, instructions for inquiries and appeals, expedited or emergency appeals, and appeal resolution.","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},640715,1793013365,{"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":39,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":11,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":144,"preview_page_count":4},7971461741311,"https://ap-avatar.wpscdn.com/avatar/74000253aff267980c6?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345379180704826","Provider Manual  \nFor our professional provider community  \nTable of Contents  \nThis manual provides information foryour CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.(CareFirst) patients.  \nPer the terms of the Participation Agreement, all providers are required to adhere to all policies and procedures contained in this manual, 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 Director CareFirst on Call. Through these channels, simple questions can be answered quickly.  \nRead and print the Guidelines for  Provider Self‑Services.  \nProvider Quick Reference Guide  \nAdministrative Functions  \nMedical credentialing  \nVerify provider information requirement Profile score  \nRole of the primary care provider (PCP)—(BlueChoice only)  \nOB/GYNs as PCPs  \nBack‑up coverage  \nAfter hours care  \nOpen/closed panel  \nReduction, suspension or termination of privileges  \nQuality of care terminations All other sanctions or terminations Member to be held harmless  \nReimbursement  \nFee schedule—place of service code assignments  \nHealth Insurance Portability and  \nAccountability Act (HIPAA) compliant codes  \nConcierge services policy Administrative services policy Notice of Payment (NOP)/Electronic Remittance Advice (ERA)  \nReimbursement for Limited Licensed Providers  \nPhysician assistants, anesthesia assistants, assistant behavior analysts and registered behavior technicians  \nReferrals (BlueChoice only)  \nElectronic capabilities  \nElectronic claims  \nElectronic Remittance Advice (ERA)  \nElectronic Fund Transfer (EFT)  \n Table of Contents  \nPaper claims submission process Timely filing of claims  \nReconsideration  \nGuidelines for ancillary claims filing Medicare crossover claims submission Effective follow‑up for claims  \nStep‑by‑step instructions for effective follow‑up  \nClaims overpayment  \nCollection of retroactively denied claims Inquiries  \nInstructions for submitting an inquiry  \nAppeals  \nInstructions for submitting an appeal Expedited or emergency appeals process Appeal resolution  \nMember complaints  \nCoordination with other payers  \nCoordination of benefits (COB)  \nSubrogation  \nNo‑fault automobile insurance Workers’ compensation Office injectable drugs  \nStandard reimbursement methodology Exemptions to standard pricing methodology  \nMedical injectables  \nPlace of Service Code Assignments  \nFacility payment rate  \nFreestanding ambulatory surgery center (ASC) rate  \nNon‑facility payment rate  \nCare Management  \nQuality improvement (QI) program  \nQI program goals and objectives  \nQI committees  \nPerformance data  \nNational Committee for Quality Assurance (NCQA)  \nPatient‑Centered Medical Home (PCMH) program  \nDisease management programs  \nRespiratory diseases (asthma, COPD) COPD resources/related links  \nDiabetes  \nDiabetes resources/related links  \nHeart disease  \nHeart disease resources/related links Oncology  \nClinical resources  \nMedical record documentation standards Complex case management (CCM) Outpatient pre‑treatment authorization plan (OPAP)  \nCoordinated home care and home hospice care  \nHospital transition of care (HTC)  \nComprehensive medication review (CMR) program  \nBehavioral health and substance use disorder program (BSD)  \nIntake, Assessment and Appointment team  \nMandatory second surgical opinion program (MSSOP)  \nUtilization Control Program (UCP)/  \nUtilization Control Program Plus (UCP+)  \nArranging for Care—BlueChoice Only  \nReferral process  \nExtended (long‑standing) referrals Services requiring a written referral Services not requiring a ","cbCaioLOjRD9KD6N","https://ap.wps.com/l/cbCaioLOjRD9KD6N","pdf",3622194,"English","# Administrative Functions\n## Medical credentialing\n## Reimbursement and fee schedule\n## Electronic claims and remittance\n# Claims Processing\n## Paper claims and timely filing\n## Reconsideration and appeals\n## Member complaints\n# Care Management and Quality Improvement\n## Quality improvement program\n## Care management programs\n## Utilization control\n# Policies and Procedures\n## Confidentiality and privacy\n## Coding and claim adjudication\n## Reporting guidelines and reimbursement methodologies","[{\"question\":\"What are providers required to follow in the CareFirst Participation Agreement?\",\"answer\":\"Providers must adhere to applicable policies and procedures contained in the manual, as required by the Participation Agreement.\"},{\"question\":\"How are provider and member questions handled regarding eligibility, benefits, or claim status?\",\"answer\":\"The manual directs providers to use CareFirst self-service channels (including CareFirst on Call and CareFirst Director), which can answer simple questions quickly.\"},{\"question\":\"Which parts of the manual cover claims handling and disputes?\",\"answer\":\"Claims processing sections include submission processes, timely filing, reconsideration, instructions for inquiries and appeals, expedited or emergency appeals, and appeal resolution.\"}]","Provider Manual - CareFirst Provider Community - 2019 Provider Guide | PDF",1792710551,227]