Healthcare Providers

During this challenging and unprecedented event, CareFirst wants to keep you informed of the benefit updates we are making to ensure our members, your patients, have access to the care they need.

Billing for Coronavirus Treatment

CareFirst is waiving cost sharing (copays, coinsurance and deductibles) for in-network or out-of-network visits to a provider’s office, lab fees or treatments related to COVID-19. Though CareFirst is waiving out-of-pocket costs, members may experience balance billing from out-of-network providers.

Providers should not collect copays for these services. If a member does owe a copay or coinsurance after the claim is processed, you can bill the member as you do for all other claims.

Submitting Claims for Office Visits, Urgent Care or ER Visits

Submit claims for office visits, urgent care, or ER visits for the purpose of diagnosing or ordering testing for COVID-19 using ICD-10 primary diagnosis code of Z20.828 regardless of the place of service. Use the following ICD-10 reporting codes for billing COVID-19 treatment:

  • Treatment of coronavirus- use code U07.1 as primary diagnosis code
  • Treatment of comorbidity symptoms should be submitted with the appropriate diagnosis code

Submitting Testing Claims

Submit claims for COVID-19 testing using Healthcare Common Procedure Coding System (HCPCS) procedure code U0002 effective for dates of service on or after 2/4/2020 or Current Procedural Terminology (CPT) code 86735 effective for dates of service on or after 3/13/2020.

Lab Services

For the duration of this public health emergency, CareFirst has expanded the scope of our contracted lab partners to support access to testing as it becomes available. As part of this expansion, providers and BlueChoice members are not limited to using LabCorp for COVID-19 testing. COVID-19 tests may be sent to any lab contracted with CareFirst authorized to perform the testing, including hospital-based labs.

During this challenging and unprecedented event, CareFirst wants to keep you informed of the benefit updates we are making to ensure our members, your patients, have access to the care they need.

Telemedicine Guidelines

CareFirst is encouraging members to call their doctor’s office if they have symptoms of the flu, COVID-19 or other contagious conditions. During this public health event, we understand the use of telemedicine is a practical option for members who wish to or should stay home. Therefore, we are waiving cost sharing* (copays, coinsurance and deductibles) for members when they have a telemedicine visit with an in-network provider. Providers are encouraged not to collect member cost sharing for these services. If a member does owe a copay or coinsurance after the claim is processed, you can bill the member as you do for all other claims. For these purposes we’ve defined telemedicine as a combination of interactive audio and video.

Telemedicine Capability

If your practice has its own telemedicine capability (audio/video), proceed with visits and bill CareFirst as normal with a place of service “02” and refer to this guidance for accepted telemedicine procedure codes and modifiers. Services for diagnosis, consultation or treatment provided through telemedicine must meet all the requirements of a face-to-face consultation or contact between a licensed health care provider and a patient consistent with the provider's scope of practice for services appropriately provided through telemedicine services.

If the claim is to evaluate a member for coronavirus, use diagnosis code Z20.828 (Exposure to viral disease). If you are treating a member with confirmed coronavirus use diagnosis code B97.29 for dates of service prior to 4/1/20 and diagnosis code U07.1 for dates of service on and after 4/1/20. Utilization review may be performed. Documentation in the medical record must support the services rendered.

If you are currently not set up to conduct telemedicine, you can use a commercially available platform to conduct telemedicine visits. The Office for Civil Rights (OCR) at the HHS has stated that providers may use commercially available video chat services to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules during the COVID-19 nationwide public health emergency. Guidance and frequently asked questions can be found on their website.

Additionally, CareFirst is amending its Medical Policy on a temporary basis to pay for phone consultations provided by physicians and nurse practitioners credentialed in CareFirst’s network for the following specialties: primary care provider, OB/GYN, family practice and pediatrics. CareFirst will pay a $20 flat fee for CPT 99441.* We selected this code for all phone visits, regardless of the amount of time. This is in effect through April 17, 2020. At the end of the 30 days, CareFirst will re-evaluate if the policy should be extended for a longer period of time.

* These benefits are covered for our fully insured members. We are also partnering closely with our self-insured customers to implement similar measures.

During this public health emergency, CareFirst is encouraging members to call their doctor’s office and utilize telemedicine options when available. We understand the use of telemedicine is a practical option for members who wish to or should stay home. Therefore, we are waiving cost sharing* (copays, coinsurance and deductibles) for members when they have a telemedicine visit with an in-network provider. Providers are encouraged not to collect member cost sharing for these services. If a member does owe a copay or coinsurance after the claim is processed, you can bill the member as you do for all other claims. For these purposes we’ve defined telemedicine as a combination of interactive audio and video.

Telemedicine Capability

If your practice has its own telemedicine capability (audio/video), proceed with visits and bill CareFirst as normal with a place of service “02” and refer to this guidance for accepted telemedicine procedure codes and modifiers. Services for diagnosis, consultation or treatment provided through telemedicine must meet all the requirements of a face-to-face consultation or contact between a licensed health care provider and a patient consistent with the provider's scope of practice for services appropriately provided through telemedicine services. Utilization review may be performed. Documentation in the medical record must support the services rendered.

If you are currently not set up to conduct telemedicine, you can use a commercially available platform to conduct telemedicine visits. The Office for Civil Rights (OCR) at the HHS has stated that providers may use commercially available video chat services to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules during the COVID-19 nationwide public health emergency. Guidance and frequently asked questions can be found on their website.

CareFirst is amending its Medical Policy on a temporary basis to pay a $20.00 flat fee for phone consultations provided by behavioral health providers in CareFirst’s network. Psychiatrists and Nurse Practitioners should use CPT 99441.* Psychologists, Licensed Certified Social Workers and Licensed Professional Counselors should use code 98966. We selected these codes, as check-ins for all phone visits, regardless of the amount of time. This is in effect through April 17, 2020. At the end of the 30 days, CareFirst will re-evaluate whether the policy should be extended for a longer period.

* These benefits are covered for our fully insured members. We are also partnering closely with our self-insured customers to implement similar measures.

During this public health emergency, CareFirst is encouraging members to call their doctor’s office and utilize telemedicine options when available. We understand the use of telemedicine is a practical option for members who wish to or should stay home Therefore, we are waiving cost sharing* (copays, coinsurance and deductibles) for members when they have a telemedicine visit with an in-network provider. Providers are encouraged not to collect member cost sharing for these services. If a member does owe a copay or coinsurance after the claim is processed, you can bill the member as you do for all other claims. For these purposes we’ve defined telemedicine as a combination of interactive audio and video.

Telemedicine Capability

If your practice has its own telemedicine capability (audio/video), proceed with visits and bill CareFirst as normal with a place of service “02” and refer to this guidance for accepted telemedicine procedure codes and modifiers. Services for diagnosis, consultation or treatment provided through telemedicine must meet all the requirements of a face-to-face consultation or contact between a licensed health care provider and a patient consistent with the provider's scope of practice for services appropriately provided through telemedicine services. Utilization review may be performed. Documentation in the medical record must support the services rendered.

If you are currently not set up to conduct telemedicine, you can use a commercially available platform to conduct telemedicine visits. The Office for Civil Rights (OCR) at the HHS has stated that providers may use commercially available video chat services to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules during the COVID-19 nationwide public health emergency. Guidance and frequently asked questions can be found on their website. Phone consultations are not reimbursable

* These benefits are covered for our fully insured members. We are also partnering closely with our self-insured customers to implement similar measures.


COVID-19 Prior Authorization Process

CareFirst has implemented the following Utilization Management policies and practices to reduce administrative burdens on the healthcare system. We stand alongside our hospital and provider networks, working to reduce unnecessary barriers so hospital staff and providers can care for COVID-19 patients when they need it most.

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Non-Elective Inpatient Admissions

For the duration of the coronavirus pandemic, CareFirst is relaxing its authorization requirements for inpatient admissions (non-elective). Notification by the facility to CareFirst will be required within 72 hours of an individual admission. Once we receive notification of the admission, we will authorize a 30-day length of stay to offer assurance to providers that the claim will be paid, alleviating pressure on hospital staff to request authorization extensions. CareFirst will not perform concurrent review during this 30-day period. If authorization is required beyond the 30 days, the facility will need to contact our Hospital Transition of Care nurses to assist with an authorization extension. We are here to help! CareFirst is extending an offer to support your team in discharge planning. Our Hospital Transition of Care nurses are available to help alleviate the pressure on hospital case managers and discharge planners. We request that facility case managers/discharge planners contact our Transition of Care team to request assistance with transition of care, discharge planning and placement support for any CareFirst member.

Emergency Admissions

For the duration of the coronavirus pandemic, CareFirst is relaxing its authorization requirements for emergency admissions. CareFirst will not require authorization for admissions through the emergency room. Notification by the facility to CareFirst will be required within 72 hours of an individual admission. Once we receive notification of the admission, we will authorize a 30-day length of stay to offer assurance to providers that the claim will be paid, alleviating pressure on hospital staff to request authorization extensions. CareFirst will not perform concurrent review during this 30-day period. If authorization is required beyond the 30 days, the facility will need to contact our Hospital Transition of Care nurses to assist with an authorization extension.

Inpatient Emergency Surgeries

For the duration of the coronavirus pandemic, CareFirst is relaxing its authorization requirements for inpatient emergency surgeries. CareFirst will not require authorization for emergency inpatient surgeries.

Facility to Facility Transfers (to increase bed capacity)

For the duration of the coronavirus pandemic, CareFirst is relaxing its authorization requirements for inpatient admissions. Notification by the receiving facility to CareFirst will be required within 72 hours of an individual admission. Once we receive notification of the admission, we will authorize a 30-day length of stay to offer assurance to providers that the claim will be paid, alleviating pressure on the receiving facility’s staff to request authorization extensions. CareFirst will not perform concurrent review during this 30-day period. If authorization is required beyond the 30 days, the facility will need to contact our Hospital Transition of Care nurses to assist with an authorization extension. We are here to help! CareFirst is extending an offer to support your team in discharge planning. Our Hospital Transition of Care nurses are available to help alleviate the pressure on hospital case managers and discharge planners. We request that facility case managers/discharge planners contact our Transition of Care team to request assistance with transition of care, discharge planning and placement support for any CareFirst member.

Transfers to Skilled Nursing Facilities (SNF), Long-Term Care (LTC) Facilities and Acute Rehabilitation

For the duration of the coronavirus pandemic, CareFirst is relaxing its authorization requirements for SNF/LTC and acute rehabilitation admissions (based on member eligibility and benefit limitations). Notification by the receiving facility to CareFirst will be required within 72 hours of an individual admission. Once we receive notification of the admission, we will authorize a 30-day length of stay to offer assurance to providers that the claim will be paid, alleviating pressure on the receiving facility’s staff to request authorization extensions. CareFirst will not perform concurrent review during this 30-day period. If authorization is required beyond the 30 days, the facility will need to contact our Hospital Transition of Care nurses to assist with an authorization extension. We are here to help! CareFirst is extending an offer to support your team in discharge planning. Our Hospital Transition of Care nurses are available to help alleviate the pressure on hospital case managers and discharge planners. We request that facility case managers/discharge planners contact our Transition of Care team to request assistance with transition of care, discharge planning and placement support for any CareFirst member.

Non-Emergent Ground Ambulance Transportation

For the duration of the coronavirus pandemic, CareFirst is relaxing its authorization requirements for non-emergent ground ambulance transportation. No authorization is required.

Non-Emergency Air Transport

Authorization and clinical review are required for non-emergency air transport.

Elective Surgeries

Prior authorization is required for elective surgeries. For elective procedures where authorizations have already been submitted, CareFirst will honor those initial authorizations which have been approved and maintain them in an approved status for up to 12 months pending member eligibility. When surgeries are rescheduled, it will be the responsibility of the provider to contact the CareFirst Utilization Management Department (866-773-2884 or via the provider portal) and provide the new date of service to ensure the claims will pay appropriately.

Homecare

As the need for hospital beds increases, more and more patients will be moving to the home setting for alternate levels of care. CareFirst will work to reduce barriers to assist patients who are discharged to protect them from unnecessary exposure. For the duration of the coronavirus pandemic, CareFirst is relaxing its authorization requirements for homecare. CareFirst will increase the length of its initial authorization to include up to 30 days of home care services.

Hospice

For the duration of the coronavirus pandemic, CareFirst is relaxing its authorization requirements for hospice. CareFirst will increase the length of its initial authorization to include up to 90 days.  

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Frequently Asked Questions

Have questions about home birth, telemedicine or other policies? Check below for the latest updates.

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Does CareFirst Require Prior Authorization for Durable Medical Equipment?

CareFirst only requires prior authorization on high dollar equipment for our HMO business.

During this public health emergency are there changes to your denials and appeals timeframe?

Timeframes are determined by our regulatory bodies based on jurisdiction.

Does CareFirst Require Prior Authorization for Emergency Ground Ambulance Transportation?

CareFirst does not require prior authorization for emergency ground ambulance transportation.

Does CareFirst Require Prior Authorization for Emergency Air Transport?

CareFirst does not require prior authorization for emergency air transport to the closest facility capable of caring for the unstable patient. All unstable COVID-19 patients requiring air transport should be treated as emergent and will not require authorization as long as it is to the closest capable facility.

Does CareFirst Medical Policy Cover Home Births Performed by OBGYNs or Certified Nurse Midwives/Direct Midwives?

Per our Global Maternity Care Medical Policy (4.0.1.66A), home birth services are covered when the member has maternity coverage. When billing for home deliveries, use place of service code 12 and refer to the provider guidelines in the Global Maternity Care Medical Policy (4.0.1.66A) for procedure coding guidance.

Does CareFirst cover services by Certified Nurse Midwives and Direct Entry Midwives?

Yes, as long as they have an arrangement with a physician to be available if needed. If needed, the physician could provide care in the home or in the hospital.

Are my CareFirst patients eligible for a telemedicine visit?

In general, all CareFirst members have coverage for telemedicine visits through the provider office or through CareFirst Video Visit.

What official information does CareFirst provide about telemedicine?

The CareFirst Professional Provider Manual outlines the telemedicine policy. Additionally, more information can be found in CareFirst’s Telemedicine Medical policy (2.01.072A). If you have further questions, please reach out to your Provider Relations Representative or Practice Consultant for assistance.

How does the CareFirst Video Visit service work?

CareFirst Video Visit is provided for members who do not have a relationship with a physician in the community. CareFirst prefers that members contact a health care provider in the community, if they have one.

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State and Local Guidance

Maryland

The Maryland Department of Health (MDH) has provided guidance on testing for COVID-19. MDH is updating their websites daily.

Washington, D.C.

Washington, D.C. Health Department’s (DC Health) has issued DC Health Testing and Personal Protective Equipment Recommendations. DC Health is updating their website daily.

Member Benefit Updates

CareFirst is constantly working to ensure our members have access to the care and resources they need. As of March 16, CareFirst has taken the following actions on behalf of our fully insured members and the community:

  • Eliminated prior authorization requirements for medically necessary diagnostic tests and covered services related to COVID-19 diagnosis.
  • Waived early medication refill limits on 30-day maintenance medications.
  • Worked with our pharmacy partners to provide free delivery of medications and assist with mailing prescriptions.
  • Waived cost sharing (copays, coinsurance and deductibles) for in-network or out-of-network visits to a provider’s office, lab fees or treatments related to COVID-19. Though CareFirst is waiving out-of-pocket costs, members may experience balance billing from out-of-network providers.
  • Encouraged the use of our 24/7 nurse phone line to virtually access clinical resources trained in the latest screening and testing referral protocols.
  • Encouraged the use of telemedicine and virtual sites of care such as CareFirst Video Visit as well as telemedicine offered by in-network providers.
    • For the duration of this public health emergency, CareFirst is waiving coinsurance, copays and deductibles for telemedicine visits with in-network providers. Member cost sharing is also waived for CareFirst Video Visit.
    • For clinician staff of primary care, general practice, internal medicine, pediatrics, OBGYN and associated nurse practitioners, CareFirst will pay for telephone consultations during this public health emergency, with no member out-of-pocket cost.
  • Rapidly expanded the scope of our contracted lab partners to support access to testing as it becomes available.

We are also partnering closely with our self-insured customers to implement similar measures.

Please continue to check back to this site as we will be making regular updates.