Inquiries & Appeals

Provider Inquiries

Inquiries may include issues pertaining to: Authorizations, Correct Frequency, ICD-10, Medical Records, Procedures/Codes and Referrals.

Instructions for Submitting an Inquiry:

Inquiries should be submitted electronically through CareFirst Direct’s Inquiry Analysis and Control System (IASH) function.

If you cannot access CareFirst Direct, please use the Provider Inquiry Resolution Form (PIRF) to submit an Inquiry.

Helpful Tips when completing a PIRF:

• Use a separate form for each patient
• Include the entire subscriber identification number, including the prefix
• Attach a copy of the claim with any additional information that might assist in the review process

An Inquiry must be submitted within 180 days or 6 months from the date of the Explanation of Benefits.

Please allow 30 days for a response.

Before sending an Inquiry, consider submitting a corrected claim that will replace the original claim submitted.

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Provider Appeals

An Appeal is a formal written request to the Plan for reconsideration of a medical or contractual adverse decision.

Instructions for Submitting an Appeal

Please submit an Appeal via a letter on your office letterhead describing the reason(s) for the Appeal and the clinical justification/rationale. Please be sure to include:

• Patient name and identification number
• Claim number
• Admission and discharge dates (if applicable) or date(s) of service
• A copy of the original claim or EOB denial information and/or denial letter/notice
• Supporting clinical notes or medical records including: lab reports, X-rays, treatment plans, progress notes, etc.

An Appeal must be submitted within 180 days or 6 months from the date of the Explanation of Benefits.

Please mail your Appeals to the following addresses:

Commercial Lines of Business
Administrative Appeals
Mail Administrator
P.O. Box 14114
Lexington, KY 40512-4114

Clinical Appeals
Clinical Appeals and Analysis Unit (CAU)
CareFirst BlueCross BlueShield
P.O. Box 17636
Baltimore, MD 21298-9375

All Appeal decisions are answered in writing. Please allow up to 60 days for a response to an Appeal.

IMPORTANT: Do not use a Provider Inquiry Resolution Form (PIRF) to submit an Appeal.