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Montgomery County Medical Society. Rockville Hilton. October 25, 2012. Current Initiatives. Patient Centered Medical Home (PCMH).

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Montgomery County Medical Society

Rockville Hilton

October 25, 2012

patient centered medical home pcmh
Patient Centered Medical Home (PCMH)

CareFirst launched its PCMH program in January 2011. The Program has grown to its current size quickly and now involves nearly 1,000,000 CareFirst subscribers, making it the largest program of its type in the nation. PCP participants now represent approximately 80 percent of all eligible primary care physicians in CareFirst physician networks. In the first 18 months of the program, CareFirst has significantly enhanced the tools, resources, and supports available to PCMH participants. These enhancements include:

  • A detailed online member health record and online care plan development tool available 24/7 via the internet.
  • Comprehensive data on their CareFirst patient population to identify opportunities for care improvement and cost savings.
  • Teams of registered nurses, community-based Local Care Coordinators and CareFirst Regional Care Coordinators, aligned with individual practices to help coordinate care for the sickest patients.
  • A team of PCMH Program Consultants to help participants understand and utilize the tools and data available through the program.
  • Free access to the American College of Physicians Medical Home Builder 2.0 tool to assist practices in transforming to a medical home model.
  • Dedicated member service resources for CareFirst PCMH members.
choose electronic claim submission
Choose Electronic Claim Submission

Electronic Submission (EDI):

  • Consistent data requirements versus completing a paper claim.
  • Decreases claim returns for additional information.
  • Faster payment
  • Enhances your record keeping abilities.
  • Electronic Fund Transfer (EFT) is available through Real Med, Emdeon and Allscripts.
  • Medicare secondary claims can now be submitted electronically- see the news item in>provider& physician>news section.
on line eligibility and claim status tools
On-line Eligibility and Claim Status Tools

Using CareFirst Direct and the Voice Response Unit ( VRU):

  • Saves time waiting for a Customer Service Representative.
  • When you must call, Provider Service will focus on your more complicated claim inquiries.
  • Consistent Eligibility and Claim Information is found in the on-line tools.
  • CareFirst is constantly enhancing CareFirst Direct and the VRU.
  • Make sure that your agents/vendors, that do your billing and follow-up, have access to CareFirst Direct.
  • We have several instructional webinars a month to train your staff or agents.
carefirst s website
CareFirst’s Website

“One-Stop” shopping for CareFirst information – and physicians.

  • Product and General Information manuals
  • Access to CareFirst’s Medical Policy
  • Access to CareFirst’s bi-monthly newsletter- BlueLink
  • Credentialing information in the “Quick Links” section of the website
  • Job Aids
  • Forms
  • Critical news blasts
  • Access to CareFirst Direct
  • Register for instructional Seminars and Webinars
  • Companion Guide for the 5010 transaction sets
  • ICD10 updates
new learning curriculum for providers
New Learning Curriculum for Providers

Suggested Curriculum for new providers or providers that would like a refresher:

  • Session 1- New Provider Introduction- overview of the expectations and training available for providers
  • Session 2 - Specialty Specific Contract Information (Institutional Ancillary Providers only)
  • Session 3 – Programs and Products – overview of CareFirst Products and corresponding membership cards
  • Session 4 - Claims Submission Requirements- overview of how to file claims to CareFirst
  • Session 5 – Corrected Claims Submission, Inquiry and Appeal Procedures- a “how to” for electronic claim correction. Also includes how to file an inquiry or an Appeal.
  • Session 6 – Self-Service Tools - CareFirst Direct – Eligibility and Benefits
  • Session 7 – Self-Service Tools – CareFirst Direct – Claims Status and Inquiry
  • Session 8 - Voice Response Unit (VRU)
  • Additional topic specific webinars we encourage you to take:
    • Blue Card , Blue Choice, HealthyBlue, Physical, Occupational and Speech Therapy, OB/GYN Care
email from carefirst
Email from CareFirst
  • Crucial Information is being shared via email.
  • CareFirst typically only sends email updates once a week.
  • Please sign-up to receive emails at>providers and physicians>news.
  • CareFirst only uses your email address for notification purposes.
fee schedule
Fee Schedule
  • Fee Schedule letters dated 10/1/2012 were mailed or delivered to groups with a 12/1/2012 effective date.
  • Top 100 fees we included in the mailing, and there is an email address to request additional codes (
  • For more information please refer to the letter dated 10/1/2012.
voucher enhancements
Voucher Enhancements

CareFirst is making changes to the Facets voucher format.

  • These enhancements to the format will aid in understanding the information on the voucher.
  • We anticipate these enhancements to be in the near future.
  • We will post the effective date and training webinars available for these changes on, and in the BlueLink.
npi reminder
NPI Reminder
  • The National Provider Identifier (NPI) must be used on all claims submissions.
  • This includes electronic and paper claims.