Transparency in Coverage–Information for Virginia Qualified Health Plan Members

Qualified Health Plan issuers participating in the Federally-Facilitated Marketplace are required to provide the following disclosures:

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For a non-participating provider, the member is responsible for any applicable deductible, copayment or coinsurance amounts stated in the member’s contract. The amount the plan pays for covered services is based on an allowed amount determined by the plan. If an out-of-network provider charges more than this allowed amount, the provider may bill you directly for the difference (known as balance billing). There may be certain situations in which members may not be balanced billed. Additional information regarding your consumer rights effective -1/1/21 can be found here.

Members can submit medical claims online, including mental health claims, by registering and logging in to My Account or by submitting a paper claim form. Dental, pharmacy and vision claims require completion and submission of a paper form.

Please be aware, there may be a time limit on the submission of your claim.

For contract years beginning between 1/1/2014 and 12/31/2016, Virginia members have 90 days to submit claims.

Beginning 1/1/2017, Virginia members have a one-year deadline to submit claims for submission.

However, for all contract years, if there are extenuating circumstances that would reasonably prevent the member from submitting a claim within the required timeframe, CareFirst may extend the claim submission deadline in its discretion for up to an additional one year. Virginia members should contact the customer service number on the back of their member ID card for more information about how to submit late claims for payment consideration.

If a Member fails to provide sufficient information for CareFirst to determine whether benefits are covered or payable, CareFirst will notify the Member as soon as possible, but not later than 24 hours after receipt of the claim, of the specific information necessary to complete the claims.

Claim forms are available online, please select from the following:

Members may submit completed claims to the following:

CareFirst BlueCross BlueShield
Mail Administrator
P.O. Box 14116
Lexington, KY 40512-4115
For assistance, contact Customer Service at the telephone number on your Member ID card.

Dental & Select Vision
CareFirst BlueCross BlueShield
Mail Administrator
P.O. Box 14115
Lexington, KY 40512-4115
For assistance, contact Customer Service at the telephone number on your Member ID card.

Davis Vision (Blue Vision, Blue Vision Plus)
Vision Care Processing Unit
P.O. Box 1525
Latham, NY 12110
For assistance, please call 1-800-783-5602.

CVS Caremark
RXBIN# 004336
P.O. Box 52136
Phoenix, Arizona 85072-2136
For assistance, contact Customer Service at the telephone number on your Prescription Benefit card.

Premiums are due on the first day of the month. There is a 31-day grace period within which premiums can be paid without a loss of coverage. Individual market members who are receiving an Advance Premium Tax Credit (APTC) are entitled to a longer grace period of three months within which premiums can be paid without a loss of coverage. However, CareFirst may pend payment for claims for services received during the second and third months of the grace period and these claims will be denied if premium is not brought current by the end of the three month grace period.

Claims may be denied retroactively, even after the enrollee has obtained services from the provider, for reasons such as non-payment of premiums or fraud. Benefits are no longer available for any medical or drug services after the last day of the benefit grace period.

To ensure a claim is not retroactively denied, premiums must be paid on time.

Individual market members who believe they have overpaid premium and are due a refund should contact CareFirst Customer Service at the telephone number on their Member ID card to discuss their situation.

Certain health care services, including prescription drugs, procedures and admissions may require prior authorization. Participating providers are responsible for securing prior authorization on behalf of the member. It is the member’s responsibility to secure prior authorization for services provided by non-participating providers by contacting CareFirst Prior Authorization/Case Management at 866-773-2884.

For emergency admissions, the provider is responsible for notifying CareFirst Case Management within 48 hours. Prior authorization for non-emergencies is required five days prior to service delivery. Failure to obtain prior authorization may result in denial of reimbursement.

When the Member or authorized representative requests a pre-service determination regarding Urgent/Emergent Care, then CareFirst will notify the Member or authorized representative of the benefit determination (whether adverse or not) as soon as possible, taking into account the exigencies, the earlier of 24 hours after CareFirst’s receipt of the information needed to make the benefit determination, or 72 hours after receipt of the request for coverage.

CareFirst has an exceptions process where members (or their doctors) can request coverage exceptions for non-formulary drugs. Urgent requests receive decisions within 24 hours. Non-urgent requests receive decisions within two business days.

Member initiated exception requests can be completed online or by phone/fax.


To obtain and complete the form necessary to initiate the exception process, members should log into My Account and search under Drug and Pharmacy Resources.


Members can request an exception by calling the number provided on their Prescription Benefit card or faxing the necessary information to 1-888-836-0730. The member must provide the following information:

  • Member name (as it appears on the Prescription Benefit card)
  • Prescription Benefit ID number
  • Date of birth
  • Name of drug
  • Name of prescribing doctor
  • Doctor’s phone number
  • Doctor’s fax number

If the request for a non-formulary exception is denied, members first request an internal review of that decision by calling the number provided on their Prescription Benefit card. If the denial of the non-formulary exception request is upheld through an internal review, members may then request an external review by an Independent Review Organization (IRO). Requests for an external review can also be made by calling the number provided on their Prescription Benefit card.

An Explanation of Benefits (EOB) is a statement a member receives that describes how a claim was processed for benefits, including the member’s liability for services rendered.

Electronic EOBs are available for access and view on My Account within one week of claims adjudication. Paper EOBs are mailed out to members within 1-2 business days of claims adjudication.

To aide in member comprehension, the following terms are included on all CareFirst EOBs:

  • Summary of Explanation of Benefits: An overview of how the total charges were considered in processing this claim.
  • Line Number: The line number of the claim. Each line represents an individual claim.
  • Date of Service: The date that service was rendered.
  • Service Description: A description of the services performed.
  • What Your Provider Can Charge You: The amount charged by the health care professional or facility (physician, hospital, etc.) for services provided to you or your covered dependents.
  • Provider Charges: The amount billed by your health care providers for your visit(s).
  • Your Responsibility: The amount that the provider can collect for the services indicated. The deductible and copay/coinsurance amount depends on the type of coverage you have, what other type of insurance coverage is involved, and if the provider participates in our Plan. If the payment was made to a non-participating provider, the subscriber or other designated payee, Your Responsibility will reflect the charge minus our payment and any other insurance payment, except Medicare non-assigned payments.
  • Copay: A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
  • Deductible: The amount you owe for health care services your health insurance or health plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible. The deductible may not apply to all services.
  • Coinsurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20 percent would be $20. The health insurance or plan pays the rest of the allowed amount.
  • Paid by CareFirst: The amount CareFirst paid to health care provider(s) for the services covered by this Explanation of Benefits.
  • Payee: Recipient of any applicable claim reimbursement.

Coordination of Benefits is the method by which a health insurance company determines if it should pay as primary or secondary payer of medical claims for a patient who has coverage under more than one health insurance policy. Your benefit contract governs which health plan pays primary and which pays secondary. This ensures that payments do not exceed 100% of charges for the covered services.

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