Member Identification Card Quick Reference GuideMemberidentification cards contain important membership and coverageinformation that help you correctly route your claims. Be sure toverify eligibility using CareFirst Direct or CareFirst on Callprior to rendering care.
Front of cardThe front of the member ID card containsinformation about the member, the primary care provider (PCP),copayments/coinsurance and some member benefits.
Member Name
Member ID Number
Group Number
Product Name
Primary Care Provider’s Name
Copayments/Coinsurance:
D—DeductibleCD—Combined Medical and Prescription DrugDeductibleP—PCP
S—SpecialistOV—Office VisitCC—Convenience CareUC—Urgent Care
ER—Emergency Room
Prescription Drug Program
Dental or vision coverage, if applicable:
DT—Dental TraditionalDP—Dental Preferred (PPO)DH—HMODentalPD—Pediatric Dental
AV—Adult VisionPV—Pediatric VisionVC—BlueVision
VU—BlueVision Plus
Type of out‑of‑area coverage
Plan Code:
See page 2 for plan code information.
Back of cardThe back of the member ID card includes medicalemergency assistance and mental health/substance use disordertelephone numbers, as well as instructions and an address forfiling claims and sending correspondence.
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SAMPLEMember NameJOHN DOEMember IDXIK999999999 OPEN ACCESSPCPDr.SmithGroupAYJ0(Bin #011834 PCN #0300-0000)BCBS Plan 080/580
CopayCD1200 P20 S30 OV20 CC20 UC30 ER100 RX DH
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SAMPLEThis employee benefit plan provides benefitsto you andyour eligible dependents.CareFirst BlueCross BlueShieldprovidesadministrative claims payment services only and does notassume any financial risk or obligation with respect to claims.
CareFirst BlueChoice, Inc. and CareFirst BlueCross BlueShieldare both independent licensees of the Blue Cross and Blue ShieldAssociation. HBCF (4/13)
Provider Service: 800-313-2223Pharmacy: 800-241-3371Vision:800-783-560224hr FirstHelp(Nurse): 800-535-9700MentalHealth/Substance Abuse: 800-245-7013Prior Auth/Case Management:866-773-2884Locate Out of Area Providers: 800-810-2583LocalCareFirst providers mail to:Mail AdministratorPO Box 14116 (forclaims)PO BOX 14114 (for correspondence)Lexington, KY 40512IfDental is listed as a benefit on the front of this card, fileclaims to: Mail AdministratorPO Box 14115, Lexington, KY40512-4115Vision Claims: Vision Care Processing UnitPO Box 1825,Latham, NY 12110
www.carefirst.comCustomer Service: 800-313-2223
Pharmacy services provided through CVS Caremark. Vision servicesprovided through Davis Vision.
https://provider.carefirst.com/providers/resources/carefirst-direct.pagehttps://provider.carefirst.com/carefirst-resources/provider/pdf/carefirst-on-call-reference-card-institutional-pcm1035.pdf
Member Identification Card QuickReference Guide
Member ID cards may include one of several logos identifying thetype of coverage the member has and/or indicating the provider’sreimbursem*nt level.
Product information
Products Prefixes Logo
Health Maintenance Organization (HMO)
■ BlueChoice HMO■ BlueChoice HMO Open Access
XIK, XIR, XIB, QXG, QXA, XIE, JHZ, XWZ, XIG, QXK, XIC, XIHPointof Service (POS) ■ BlueChoice Opt‑Out
■ BlueChoice Opt‑Out Plus Open Access*
■ BlueChoice Opt‑Out Open Access*
■ BlueChoice Advantage■ BlueChoice Plus
* Open Access = no referral needed if the provider is in theBlueChoiceNetwork
Preferred Provider Organization (PPO)
■ BluePreferred PPO XIL, XWV, JHJ, XII, JHI, XIQ, QXM, XIY,XIU
Federal Employee Program (FEP)
■ FEP Basic Option■ FEP Standard Option■ FEP Blue Focus
R
HealthyBlue ■ HealthyBlue Advantage■ HealthyBlue 2.0 OpenAccess■ HealthyBlue Plus Open Access
JHG, QXF, JHA, JHC, QXB, QXE, XIF, JHD, QXD, JHH, QXI, QXL, QXU,QXR, QXS, QXT, QXC, QXH
■ HealthyBlue PPO
■ HealthyBlue HMO
Maryland Point of Service (MPOS)
■ Maryland Point of Service Varies
National Account Service Company (NASCO)
■ All products, except FEP Unique prefix. CareFirst IDs haveplan codes 080/580 and 190/690.
MedPlus ■ Medigap Plan A, B, F, G, L, M, N
■ Medigap Plan High Ded F
XWC
Medicare Advantage ■ CareFirst BlueCross BlueShield AdvantageCore
■ CareFirst BlueCross BlueShield Advantage Enhanced
Prefix – MAC. CareFirst IDs have plan code 193.
Out-of-area coverage (BlueCard)
Logo description What it looks like What it means (type ofout-of-area coverage)
A blank (empty) suitcase icon
Member has out‑of‑area coverage for urgent or emergencycare.
A suitcase icon with PPO inside
Member has PPO or EPO benefits available for medical servicesreceived inside or outside of the U.S.
Focused on you.
Focused on you.
Focused on you.
CareFirst BlueCross BlueShield is the shared business name ofCareFirst of Maryland, Inc. and Group Hospitalization and MedicalServices, Inc. CareFirst BlueCross BlueShield Medicare Advantage isthe business name of CareFirst Advantage, Inc. CareFirst BlueCrossBlueShield Community Health Plan District of Columbia is thebusiness name of Trusted Health Plan (District of Columbia), Inc.In the District of Columbia and Maryland, CareFirst MedPlus is thebusiness name of First Care, Inc. In Virginia, CareFirst MedPlus isthe business name of First Care, Inc. of Maryland (used in VA by:First Care, Inc.). CareFirst of Maryland, Inc., GroupHospitalization and Medical Services, Inc., CareFirst Advantage,Inc., Trusted Health Plan (District of Columbia), Inc., CareFirstBlueChoice, Inc., First Care, Inc., and The Dental Network, Inc.are independent licensees of the Blue Cross and Blue ShieldAssociation. BLUE CROSS®, BLUE SHIELD® and the Cross and ShieldSymbols are registered service marks of the Blue Cross and BlueShield Association, an association of independent Blue Cross andBlue Shield Plans.
CUT0491-1E (11/20)
Notice of Nondiscrimination and Availability of LanguageAssistance Services(UPDATED 8/5/19)
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc.,CareFirst Diversified Benefits and all of their corporateaffiliates (CareFirst) comply with applicable federal civil rightslaws and do not discriminate on the basis of race, color, nationalorigin, age, disability or sex. CareFirst does not exclude peopleor treat them differently because of race, color, national origin,age, disability or sex.
CareFirst:
■ Provides free aid and services to people with disabilities tocommunicate effectively with us, such as:Qualified sign languageinterpretersWritten information in other formats (large print,audio, accessible electronic formats, other formats)
■ Provides free language services to people whose primarylanguage is not English, such as:Qualified interpretersInformationwritten in other languages
If you need these services, please call 855-258-6518.
If you believe CareFirst has failed to provide these services,or discriminated in another way, on the basis of race, color,national origin, age, disability or sex, you can file a grievancewith our CareFirst Civil Rights Coordinator by mail, fax or email.If you need help filing a grievance, our CareFirst Civil RightsCoordinator is available to help you.
To file a grievance regarding a violation of federal civilrights, please contact the Civil Rights Coordinator as indicatedbelow. Please do not send payments, claims issues, or otherdocumentation to this office.
Civil Rights Coordinator, Corporate Office of CivilRightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224
Email Address [emailprotected]
Telephone Number 410-528-7820 Fax Number 410-505-2011
You can also file a civil rights complaint with the U.S.Department of Health and Human Services, Office for Civil Rightselectronically through the Office for Civil Rights Complaintportal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsfor by mail or phone at:
U.S. Department of Health and Human Services 200 IndependenceAvenue, SW Room 509F, HHH Building Washington, D.C. 20201800-368-1019, 800-537-7697 (TDD)
Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html.
CareFirst BlueCross BlueShield is the shared business name ofCareFirst of Maryland, Inc. and Group Hospitalization and MedicalServices, Inc. CareFirst of Maryland,Inc., GroupHospitalization and Medical Services, Inc., CareFirst BlueChoice,Inc., The Dental Network and First Care, Inc. are independentlicensees of the Blue Cross and BlueShield Association. Inthe District of Columbia and Maryland, CareFirst MedPlus is thebusiness name of First Care, Inc. In Virginia, CareFirst MedPlus isthe business name of First Care, Inc. of Maryland (used in VA by:First Care, Inc.). The Blue Cross® and Blue Shield® and the Crossand Shield Symbols are registered service marks of the Blue Crossand Blue Shield Association, an association of independent BlueCross and Blue Shield Plans.
Foreign Language Assistance Attention (English): This noticecontains information about your insurance coverage. It may containkey dates
and you may need to take action by certain deadlines. You havethe right to get this information and assistance in
your language at no cost. Members should call the phone numberon the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogueuntil prompted to push 0. When an agent
answers, state the language you need and you will be connectedto an interpreter.
አማርኛ (Amharic) ማሳሰቢያ፦ ይህ ማስታወቂያ ስለ መድን ሽፋንዎ መረጃ ይዟል። ከተወሰኑቀነ-ገደቦች በፊት ሊፈጽሟቸው የሚገቡ ነገሮች ሊኖሩ ስለሚችሉ እነዚህን ወሳኝ ቀናት ሊይዝ ይችላል። ይኽንመረጃ የማግኘት እና ያለምንም ክፍያ በቋንቋዎ እገዛ የማግኘት መብት አለዎት። አባል ከሆኑ ከመታወቂያካርድዎ በስተጀርባ ላይ ወደተጠቀሰው የስልክ ቁጥር መደወል ይችላሉ። አባል ካልሆኑ ደግሞ ወደ ስልክቁጥር
855-258-6518 ደውለው 0ን እንዲጫኑ እስኪነገርዎ ድረስ ንግግሩን መጠበቅ አለብዎ። አንድ ወኪልመልስ ሲሰጥዎ፣ የሚፈልጉትን ቋንቋ ያሳውቁ፣ ከዚያም ከተርጓሚ ጋር ይገናኛሉ።
Èdè Yorùbá (Yoruba) Ìtẹ́tíléko: Àkíyèsí yìí ní ìwífún nípa iṣẹ́adójútòfò rẹ. Ó le ní àwọn déètì pàtó o sì le ní láti
gbé ìgbésẹ̀ ní àwọn ọjọ́ gbèdéke kan. O ni ẹ̀tọ́ láti gba ìwífúnyìí àti ìrànlọ́wọ́ ní èdè rẹ lọ́fẹ̀ẹ́. Àwọn ọmọ-ẹgbẹ́
gbọ́dọ̀ pe nọ́mbà fóònù tó wà lẹ́yìn káàdì ìdánimọ̀ wọn. Àwọnmíràn le pe 855-258-6518 kí o sì dúró nípasẹ̀ ìjíròrò
títí a ó fi sọ fún ọ láti tẹ 0. Nígbàtí aṣojú kan bá dáhùn, sọèdè tí o fẹ́ a ó sì so ọ́ pọ̀ mọ́ ògbufọ̀ kan.
Tiếng Việt (Vietnamese) Chú ý: Thông báo này chứa thông tin vềphạm vi bảo hiểm của quý vị. Thông báo có thể
chứa những ngày quan trọng và quý vị cần hành động trước một sốthời hạn nhất định. Quý vị có quyền nhận
được thông tin này và hỗ trợ bằng ngôn ngữ của quý vị hoàn toànmiễn phí. Các thành viên nên gọi số điện thoại
ở mặt sau của thẻ nhận dạng. Tất cả những người khác có thể gọisố 855-258-6518 và chờ hết cuộc đối thoại cho
đến khi được nhắc nhấn phím 0. Khi một tổng đài viên trả lời,hãy nêu rõ ngôn ngữ quý vị cần và quý vị sẽ được
kết nối với một thông dịch viên.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ngimpormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsaat maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha angimpormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro angnumero ng telepono na nasa likuran ng kanilang
identification card. Ang lahat ng iba ay maaaring tumawag sa855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagotang ahente, sabihin ang wika na kailangan mo
at ikokonekta ka sa isang interpreter.
Español (Spanish) Atención: Este aviso contiene informaciónsobre su cobertura de seguro. Es posible que
incluya fechas clave y que usted tenga que realizar algunaacción antes de ciertas fechas límite. Usted tiene
derecho a obtener esta información y asistencia en su idioma sinningún costo. Los asegurados deben llamar al
número de teléfono que se encuentra al reverso de su tarjeta deidentificación. Todos los demás pueden llamar al
855-258-6518 y esperar la grabación hasta que se les indique quedeben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicará conun intérprete.
Русский (Russian) Внимание! Настоящее уведомление содержитинформацию о вашем страховом
обеспечении. В нем могут указываться важные даты, и от вас можетпотребоваться выполнить некоторые
действия до определенного срока. Вы имеете право бесплатнополучить настоящие сведения и
сопутствующую помощь на удобном вам языке. Участникам следуетобращаться по номеру телефона,
указанному на тыльной стороне идентификационной карты. Всепрочие абоненты могут звонить по
номеру 855-258-6518 и ожидать, пока в голосовом меню не будетпредложено нажать цифру «0». При
ответе агента укажите желаемый язык общения, и вас свяжут спереводчиком.
हिन्दी (Hindi) ध्यान दें: इस सचूना में आपकी बीमा कवरेज के बारेमें जानकारी दी गई िै। िो सकता िै कक इसमें मखु्य ततथियों का उल्लेखिो और आपके ललए ककसी तनयत समय-सीमा के भीतर काम करना ज़रूरी िो। आपकोयि जानकारी और सबंथंित सिायता अपनी भाषा में तनिःशलु्क पाने का अथिकारिै। सदस्यों को अपने पिचान पत्र के पीछे हदए गए फोन नबंर पर कॉल करनाचाहिए। अन्य सभी लोग 855-258-6518 पर कॉल कर सकत ेिैं और जब तक 0दबाने के ललए न किा जाए, तब तक सवंाद की प्रतीक्षा करें। जब कोई एजेंटउत्तर दे तो उस ेअपनी भाषा बताए ँऔर आपको व्याख्याकार से कनेक्ट करहदया जाएगा।
Ɓǎsɔ́ɔ̀-wùɖù (Bassa) Tò Ɖùǔ Cáo! Bɔ ̃̌ nìà kɛ ɓá nyɔ ɓěké m̀ gbo kpá ɓó nì fu ̀ à-fṹá-tìǐn nyɛɛ jè dyí. Bɔ ̃̌nìà kɛ
ɓéɖé wé jɛ́ɛ́ ɓě ɓɛ́ m̀ ké ɖɛ wa mɔ́ m̀ ké nyuɛɛ nyu hwɛ̀ɓɛ́ wé ɓěa ké zi. Ɔ mɔ̀ nì kpé ɓɛ́ m̀ ké bɔ ̃̌ nìà kɛ kègbo-
kpá-kpá m̀ mɔ́ɛɛ dyé ɖé nì ɓíɖí-wùɖù mú ɓɛ́ m̀ ké sewíɖí ɖò pɛ́ɛ̀. Kpooɔ̀ nyɔ ɓě mɛ ɖá fṹùn-nɔ̀ɓà nìà ɖéwaà
I.D. káàɔ̀ ɖeín nyɛ. Nyɔ tɔ̀ɔ̀ séín mɛ ɖá nɔ̀ɓà nìà kɛ:855-258-6518, ké m̀ mɛ fò tee ɓɛ́ wa kéɛ m̀ gbo cɛ ɓɛ́ m̀ké
nɔ̀ɓà mɔ̀à 0 kɛɛ dyi pàɖàìn hwɛ̀. Ɔ jǔ ké nyɔ ɖò dyi m̀gɔ ̃̌ jǔǐn, po wuɖu m̀ mɔ́ poɛ dyiɛ, ké nyɔ ɖò mu ɓónììn
ɓɛ́ ɔ ké nì wuɖuɔ̀ mú zà.
বাাংলা (Bengali) লক্ষ্য করুন: এই ননাটিশে আপনার ববমা কভাশরজসম্পশকে তথ্য রশেশে। এর মশযয গুরুত্বপূর্ে তাবরখ থ্াকশত পাশর এবাংবনবদেষ্ট তাবরশখর মশযয আপনাশক পদশক্ষ্প বনশত হশত পাশর। ববনা খরশেবনশজর ভাষাে এই তথ্য পাওোর এবাং সহােতা পাওোর অবযকার আপনার আশে।সদসযশদরশক তাশদর পবরেেপশের বপেশন থ্াকা নম্বশর কল করশত হশব। অশনযরা855-258-6518 নম্বশর কল কশর 0 টিপশত না বলা পর্েন্ত অশপক্ষ্া করশতপাশরন। র্খন নকাশনা এশজন্ট উত্তর নদশবন তখন আপনার বনশজর ভাষার নামবলনু এবাং আপনাশক নদাভাষীর সশে সাংর্ুক্ত করা হশব।
یہ نوٹس آپ کے انشورینس کوریج سے متعلق معلومات پر مشتمل ہے۔ اسمیں کلیدی تاریخیں ہو سکتی ہیں اور ممکن :توجہ (Urduاردو )ہے کہ آپ کومخصوص آخری تاریخوں تک کارروائی کرنے کی ضرورت پڑے۔ آپ کے پاس یہمعلومات حاصل کرنے اور بغیر خرچہ
کو اپنے شناختی کارڈ کی پشت پر موجود فون نمبر پر کال کرنی چاہیے۔سبھی دیگر کیے اپنی زبان میں مدد حاصل کرنے کا حق ہے۔ ممبران
دبانے کو کہے جانے تک انتظار کریں۔ ایجنٹ کے جواب دینے پر اپنیمطلوبہ زبان 0پر کال کر سکتے ہیں اور 6518-258-855لوگ
بتائیں اور مترجم سے مربوط ہو جائیں گے۔
توجه: این اعالمیه حاوی اطالعاتی درباره پوشش بیمه شما است. ممکناست حاوی تاریخ های مھمی باشد و الزم است تا تاریخ (Farsiفارسی ).مقرر شده خاصی اقدام کنید. شما از این حق برخوردار هستید تا ایناطالعات و راهنمایی را به صورت رایگان به زبان خودتان دریافت کنید
شان تماس بگیرند. سایر افراد می توانند با شماره ره درج شده در پشتکارت شناساییاعضا باید با شما
را فشار دهند. بعد از پاسخگویی توسط یکی از اپراتورها، زبان 0تماسبگیرند و منتظر بمانند تا از آنھا خواسته شود عدد 855-258-6518
.مورد نیاز را تنظیم کنید تا به مترجم مربوطه وصل شوید
اتخاذ إلى تحتاج وقد مھمة، تواریخ على یحتوي وقد التأمینیة، تغطیتكبشأن معلومات على اإلخطار هذا یحتوي :تنبیه (Arabic) العربیة اللغةاالتصال األعضاء على ینبغي .تكلفة أي تحمل بدون بلغتك والمعلوماتالمساعدة هذه على الحصول لك یحق .محددة نھائیة مواعید بحلولإجراءات
الرقم على االتصال لآلخرین یمكن .بھم الخاصة الھویة تعریف بطاقةظھر في المذكور الھاتف رقم على
بھا التواصل إلى تحتاج التي اللغة اذكر الوكالء، أحد إجابة عند .0رقم على الضغط منھم یطلب حتى المحادثة خالل واالنتظار855-258-6518
.الفوریین المترجمین بأحد توصیلك وسیتم
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(Navajo)
855-258-6518
