Claims

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To file a claim online, sign in to your My Account page. Then, follow these steps:

  • In the top navigation bar, click Claims & EOBs.
  • Choose Submit a Claim Online from the drop-down menu.
  • On the next page, click the Submit a Claim button.
  • Follow the prompts.

Don’t have a My Account page? Register here.

Prefer to mail in your claim? Call the Member Services number on the back of your member ID card and ask us to send you a form.

Log in to My Account and go to the Claims tab, then select View My Claims.
Yes. You must be at least 18 years old to submit a claim. However, claim(s) payments will only be issued to the policyholder.
Yes. A single itemized bill may be used as long as all services you are submitting for payment are listed on the bill.
You may upload it once.
Yes.
Yes, a claim may be submitted after each individual treatment.
A National Provider Identifier (NPI) is a federally assigned provider number to identify the provider’s credentials and to ensure the provider is a valid medical practitioner.
This number is assigned to all businesses. In the event that the provider is not contracted with CareFirst, and/or the provider does not provide the NPI, this number is used to ensure services are rendered by a valid practitioner and are reimbursable.
Treatment provided due to accidents (non-illness, routine medical services) fall into this classification. For example, tripping over a ladder would be considered an accidental injury.
Yes, you may submit the claim. For services related to an accidental injury, CareFirst sends the subscriber/patient a questionnaire asking for more information about the accident. If another party appears to be at fault for the injury, CareFirst will seek reimbursement from the negligent party or their insurer.

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A statistical adjustment is a change to your claim that does not impact payments or dollars.
This will be noted on the E-EOB through the use of a remark code.
An upward adjustment is a change to the claim that results in a positive result for the subscriber or member on that particular claim. It may or may not impact payments or dollar amounts.
Upward adjustments will be noted on the E-EOB through the use of a remark code.
Claims that have been changed or adjusted can be compared by searching for claims by claim number on the search claims detail screen in the Claims section of My Account.
Claims that been overpaid by your insurance will be documented on the E-EOB. A separate box will display the claim number, the original payment amount, the adjustment or overpayment amount, and the remaining balance.

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An appeal is a timely request for a formal review of an adverse benefit decision, such as a claim denial or how we applied your deductible or coinsurance. An appeal may be submitted by you or your authorized representative.

A first-level appeal is the first formal internal review of the claim decision. Under most plans, first-level appeals must be filed within 180 days of the date you received your EOB. A second-level appeal is a second formal internal review of the claim decision.

Please check your health plan documents for the deadline to submit your appeal(s). On each level of appeal, a written response will be sent to you within the timeframe required by law. For plans that have two levels of appeal, a claim payment appeal is typically resolved within 30 days from the date we received your appeal request.

There is a limit to the number of times you may appeal a decision. The limits are described in your plan documents, and the response will let you know if there are additional steps you can take. In the event you have exhausted your levels of appeal, the response you receive will notify you to that effect.

To appeal a claim payment or denial, follow these steps:


Step 1: Contact Us

Call the Member Services phone number on your member ID card. If your concern is not resolved via a call with a CareFirst representative, you may submit a written appeal.

Step 2: Submit a Written Appeal

CareFirst must receive your written appeal within 180 days or six months of receiving the written notification of claim denial. Send it to Mail Administrator, P.O. Box 14114, Lexington, KY 40512. If you prefer, you can send a secure email with your request through My Account.

In the letter include:

  • Member name and ID number
  • Provider name
  • Date(s) of service
  • Admission and discharge date (if applicable)
  • A copy of the original Explanation of Benefits, voucher or bill
  • Medical records (emergency room records, X-rays, etc.)

Step 3: Appeal Decisions

All appeal decisions will be sent to you in writing and will include a detailed explanation about the decision, as well as any documentation to support the decision. You will also receive information on next steps you may take if you are not satisfied with the appeal decision.

Learn more about this process.

A written member/provider appeal can be mailed to the following address:

CareFirst BlueCross BlueShield
PO Box 14114
Lexington, KY 40512-4116

Your written member appeal should include:

  • Member name and ID number
  • Provider name
  • Date(s) of service
  • Admission and discharge date (if applicable)
  • A copy of the original Explanation of Benefits, voucher or bill
  • Medical records (emergency room records, X-rays, etc.)
  • The purpose of the appeal

You can view additional information on the Claims Appeals page.

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The following file formats are acceptable: .bmp, .jpg, .pdf, .png and .tiff.
You may attach up to 20 items with each claim. The total combined size of all attached items cannot exceed 20MB.

Questions that require phone support

The following questions are best answered by one of our Member Services experts.

  • How do I get immediate help with a change in my membership?
  • When will I get my new member ID cards?
  • How do I get proof of coverage or a letter of credible coverage?
  • How do I get help if I’m having technical issues with the website?

Support & Service

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Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card.

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Questions that Require Phone Support

The following questions are best answered by one of our Member Services experts.

  • Can you help me understand how my insurance plan works?
  • How do I get assistance with complex benefits or specific benefit issues?
  • How do I get more information about a particular treatment/service I’m considering?
  • How do I find out if I need prior authorization for a procedure?
  • What’s the status of my prior authorization request?
  • How do I know how many visits I have remaining for a specific service (e.g., physical therapy)?
  • How do I know how much money I have remaining in my allowance for a specific service (e.g., infertility treatments)?

Support & Service

View full directory

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Questions that require phone support

The following questions are best answered by one of our Member Services experts.

  • What’s the status of my claim appeal?
  • Can you explain the denial code on my benefits claim?
  • Can you help me with a claim I think has been processed incorrectly?
  • Why is my claim being adjusted?
  • Why was my claim with my in-network doctor processed as out-of-network ?
  • Can you help me figure out how much I owe and to whom?
  • Can you help me update my Coordination of Benefits (COB)?
  • Can you help me with a routine visit that requires applied a cost share/patient liability?
  • What’s the status of my over-accumulation review?

Support & Service

View full directory

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card.

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Questions that require phone support

The following questions are best answered by one of our Member Services experts.

  • I can’t find a medical specialist for a specific issue. Can you help me?
  • I can’t find a mental health specialist for a specific issue. Can you help me?
  • Can you help me find an in-network doctor who doesn’t appear when using the Find a Doctor tool?
  • Do I need prior authorization for a procedure I’m considering?
  • Do I need a referral to see a specialist?
  • Can you tell me if a doctor who’s not listed as a pediatrician works with children?

Support & Service

View full directory

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card.

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Questions that require phone support

The following questions are best answered by one of our Member Services experts.

  • How can my healthcare plan help me save money?
  • Am I eligible for any non-medical discounts through CareFirst?

Support & Service

View full directory

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card.

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

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