Membership, Product Information and Sample ID Cards Membership Member’s Rights and Responsibilities

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Membership, Product Information and
Sample ID Cards
This guide provides information for
CareFirst BlueCross BlueShield, CareFirst
BlueChoice, Inc., and The Dental Network
(collectively CareFirst) Dental providers.
Membership
Member’s Rights and Responsibilities
Members have a right to:
e treated with respect and recognition of their
b
dignity and right to privacy
n receive information about the Health Plan, its
services, its practitioners and providers, and
members rights and responsibilities
n participate with practitioners in making
decisions regarding their health care
n discuss appropriate or medically necessary
treatment options for their conditions,
regardless of cost or benefit coverage
n make recommendations regarding the
organization’s members’ rights and
responsibilities policies
n voice complaints or appeals about the their plan
or the care provided
n provide, to the extent possible, information
that the Health Plan and its practitioners and
providers need in order to care for them
n understand their health problems and
participate in developing mutually agreed upon
treatment goals to the degree possible
n follow the plans and instructions for care that
they have agreed on with their practitioners
n pay member copayments or coinsurance at the
time of service
n be on time for appointments and to notify
practitioners/providers when an appointment
must be canceled
n
Per the terms of the Participating
Agreement, all providers are required
to adhere to all policies and procedures
contained in this guide, as applicable. If
we make any administrative or procedural
changes, we will update the information
in this guide and notify you through email
and BlueImpressions, our online Dental
provider newsletter.
Specific requirements of a member’s
Dental 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 Direct or the Voice Response
Unit. Through these channels, simple
questions can be answered quickly.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
PM0018 (11/13)
DENTAL | PROVIDER MANUAL
CONTENTS
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Membership, Product Information and Sample ID Cards
Dental Products
CareFirst Individual Select Preferred (ISP)
Traditional Dental members may seek treatment
from any Participating Provider in the network.
Reimbursement is based on 100 percent of the
Traditional Allowed Benefit (AB) with applicable
deductibles and co-insurance. Members seeking
treatment from non-participating providers receive
100 percent of the AB for covered services, subject to
deductibles, co-insurance and balance billing.
The Individual Select Preferred (ISP) is designed
to utilize the CareFirst Participating and Preferred
Provider Networks. This product offers its enrollees
full coverage for Preventive/Diagnostic (Class I)
services provided the services are performed by an
in-network dentist. Participating Providers are only
required to file claims for Class I services. Services
in the Class II, III, IV and V categories may be billed
directly to the member at the time of service, at the
provider’s usual charge.
CareFirst Preferred Dental
Identifying Product Type by Indicator
CareFirst Traditional Dental
Preferred Dental Members may seek treatment
from any Preferred Dental Provider in the network.
Reimbursement is based at 100 percent of the
Preferred Allowed Benefit with applicable deductibles
and coinsurance. Members seeking treatment from
participating (not a preferred provider) receive
benefits at a reduced rate and are subject to billing
up to the Traditional Allowed Benefit. Members
seeking treatment from non-participating providers
receive benefits at a reduced rate and are subject to
deductibles, coinsurance and balance billing.
CareFirst BlueChoice and The Dental Network
(DHMO)
DHMO members are required to select a general
dentist who participates in their plan as their primary
care dentist. If members do not select a primary care
dentist, one will be assigned. If a member needs to
see a specialist for dental procedures, they should
obtain a referral from their primary care dentist to an
in-network specialist.
All membership ID cards have a dental indicator that
tells what type of dental plan covers the member.
T raditional Dental members are identified by the DT
indicator on their ID card
n Preferred Dental members are identified by the DP
indicator on their ID card
n Individual Select Preferred Dental members are
identified by the DS indicator on their ID card
n DHMO Dental members are identified by the DH
indicator on their ID card
n NASCO cards may display the DT/DP indicator or a
variation of Dental titles. Examples are Dent Trad,
Dent PPO, etc
n
CareFirst BlueChoice Discount Dental Program
Discount Dental is a free discount program offered to
all CareFirst BlueChoice Medical HMO members at no
additional cost. Members have access to any provider
who participates in DHMO Discount Dental Program
and can receive discounts on dental services through
this program. Because it is a discount program and
not a covered benefit, there are no claim forms,
referrals or paperwork to complete. Members must
show their CareFirst BlueChoice membership card and
pay the discounted fee at the time of service to save.
DENTAL | PROVIDER MANUAL
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Membership, Product Information and Sample ID Cards
Sample ID Cards
Sample ID Cards
Traditional Dental
BlueChoice DHMO
Member Name
JOHN DOE
Member ID
XIC999999999
Member Name
JOHN DOE
Member ID
XWY999999999
BCBS Plan 190/690
Group 1900000-0A00
Eff Date 01/01/08
Coverage Type
BC-365 BS-C DIAG4 MM ND P907
CITY BALTO/BFG-DT
Plan Benefits
Group
AYJ0
(Bin #011834 PCN #0300-0000)
BCBS Plan 080/580
OPEN ACCESS
PCP Name
Dr. SMITH
Copay
CD1200 P20 S30 ER100 RX DH
BlueChoice Discount Dental
Preferred Dental
Member Name
JOHN DOE
Member ID
XIL999999999
Member Name
JOHN DOE
Member ID
XIK999999999
Group
0000000-0000
Group
AYJ0
(Bin #011834 PCN #0300-0000)
BCBS Plan 080/580
(Bin #011834 PCN #0300-0000)
BCBS Plan 080/580
P10 S20 ER25 DP
OPEN ACCESS
PCP Name
Dr. SMITH
Copay
CD1200 P20 S30 ER100 RX
PPO
Individual Select Preferred
The Dental Network (DHMO)
Subscriber Name
JOHN DOE
Subscriber ID
TDN00000001
Group No.
Dental Plan
Effective Date
Provider Office
12345
PC-10
1/1/2009
9999
ABC DENTAL ASSOCIATES
800-888-8888
Dependents
DEPENDENT
DEPENDENT
DEPENDENT
02
03
04
9999
9999
9999
DENTAL | PROVIDER MANUAL
Member Name
JOHN DOE
Member ID
XIC999999999
Group
AYJ0
(Bin #011834 PCN #0300-0000)
BCBS Plan 080/580
OPEN ACCESS
PCP Name
Dr. SMITH
Copay
CD1200 P20 S30 ER100 RX DS
CONTENTS
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Membership, Product Information and Sample ID Cards
National Accounts
FEP Basic
Government-Wide
Service Benefit Plan
Basic
Federal Employee Program
Member Name
JOHN DOE
Member ID
RAS 81XXXXXXX
NATIONAL ACCOUNT
Group
1900000-OA00
BC-365 BS-C DIAG4
MMDP
Eff Date 11/19/11
BCBS Plan 690/190
Coverage H&W
NCAS
www.fepblue.org
Member Name
JOHN DOE
Member ID
R30048852
Enrollment Code
Effective Date
112
01/01/2008
RxBIN
RxPCN
RxGrp
610415
PCS
65006500
FEP Standard
Government-Wide
Service Benefit Plan
PPO
Federal Employee Program
Member Name
JOHN DOE
Member ID
ABCX12345
Type of Coverage
Family
Group No. ABC
Benefit Plan Traditional Dental
Effective Date 06/01/09
www.fepblue.org
Member Name
JOHN DOE
Member ID
R30048852
Enrollment Code
Effective Date
105
01/01/2008
RxBIN
RxPCN
RxGrp
610415
PCS
65006500
CareFirst Administrators
Member Name
JOHN DOE
Member ID
ABCX12345
Group No.
Benefit
CARRIER/GR
Effective Date
BCBS
Coverage Level
Family
ABCD
PREMIER
BC02/2001
1/1/2009
192/692
Copay
OV10
DENTAL | PROVIDER MANUAL
CONTENTS
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