Carefirst claims not processing

[Anonymous]

Anonymous wrote:I’m new to carefirst this year and have had about 20 claims since 1/1/2026 all processed in a very timely manner. I guess it was just luck? Several different providers in Va and Md for 3 family members

Were these in network? Only my OON claims are not processing.

[Anonymous]

I wonder if there is a problem with the credentialing of these OON providers.

[Anonymous]

Anonymous wrote:I wonder if there is a problem with the credentialing of these OON providers.

For me, they are providers I have used for years and prior to 2026, filed claims and got reimbursed for my share. It appears to be a system problem at Carefirst, but there has to be a limit on how long they can go without paying out claims.

[Anonymous]

Same here - have track record from 12/31/2025 and prior of years of mostly efficient Carefirst processing of out of network claims. Since 1/1/2026 only in network claims have been processed, and those with significant delay. All OON claims submitted since 1/1/2026 remain in “Processing” status. From on what I see on this thread and elsewhere it seems to be some type of systems update issue. I’m sympathetic to the challenges of systems integration, to a point. However now three months in on whatever the problem is, there has been no communication from Carefirst indicating the issue is identified or in process of correction.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I wonder if there is a problem with the credentialing of these OON providers.

For me, they are providers I have used for years and prior to 2026, filed claims and got reimbursed for my share. It appears to be a system problem at Carefirst, but there has to be a limit on how long they can go without paying out claims.

Same here. These are out of network providers I have been seeing (and getting reimbursements from BCBS) for years.

I'm going to start making phone calls to the insurance company I guess. Won't do much good but at least I can annoy them.

[Anonymous]

It’s almost like they are “punishing” you for using OON providers. Which is ridiculous since your policy specifically states you can use OON providers.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I wonder if there is a problem with the credentialing of these OON providers.

For me, they are providers I have used for years and prior to 2026, filed claims and got reimbursed for my share. It appears to be a system problem at Carefirst, but there has to be a limit on how long they can go without paying out claims.

You would think, but there seem to be no consumer protections on this front. I have been stunned that:
1. During open enrollment, CareFirst would not tell me what the allowable amount is for a specific service, even with the codes from the provider.
2. There is no disincentive for lying to consumers. CareFirst lied to me on the phone and via online messages multiple times, claiming my policy didn't cover certain services. They even sent me a random document that didn't apply to my policy. You can contest things and get the state involved and get your claims paid out eventually, but there is no penalty to the insurer for lying.
3. On the flip side I have had more than one provider that takes my insurance try to balance bill or simply refuse to correctly submit to insurance. Mistakes happen, but when it takes multiple long phone calls and emails to resolve something like this and me explicitly having to explicitly tell them they are prohibited from balance billing, it's clear that they are just pushing things to see what they can get away with. Some percentage of people will just give up and pay rather than deal with the massive hassle they intentionally create.

[Anonymous]

I’ve had Carefirst coverage for MANY years and never experienced anything like this. All of the theories presented above for delays may be accurate at some level (trying to discourage use of OON, force appeals, and the like). But I also think the pattern seen - timely professing of OON claims through 12/31/25 and then complete lack of OON claim processing and intermittent processing of in-network claims since 1/1/26 tells me they are having a system wide update/integration disaster.

Both Carefirst and my employer HR office have been completely in ineffective at communicating on this. In the meantime I am many $1,000’s of dollars out of pocket on OON medical expenses and struggling to pay my day to day bills. Just like that I’ve gone from feeling insurance blessed to cursed….

[Anonymous]

4 months out they have not paid the bill doctors office is pissed. If I pay it I don't think I'll ever get refunded from BCBS.

What the heck is going on?

[Anonymous]

Re-upping this, as I am the person who had this interaction with the Carefirst rep and I think the explanation he gave me (esp. the bold) was accurate.

I did, nevertheless, subsequently submit a complaint to the Maryland Insurance Administration, because I think what the Carefirst rep said could be true and the company could still be opportunistically using it as a means of discouraging OON claims, which is BS.

https://insurance.maryland.gov/Pages/default.aspx

Anonymous wrote:Update to anyone dealing with this.

I am on the phone with a Carefirst rep now (it was a 30-minute wait). He has explained, clearly reading a script that he has read many times already, that on January 1, Carefirst changed systems and this added 2-3 minutes to every single transaction they perform. Allegedly the system change was needed because they are so frequently the victims of cyberattacks.

According to this CSR, OON claims are massively backed up because the providers have to be re-entered into the system one by one before any claims pertaining to them can be adjusted.

He is unaware of any process via which that can be expedited, and has no ETA to completion.

The script said to expect 45-60 days instead of 30-60. My claims are already three months old.

[Anonymous]

Anonymous wrote:I’m one of the PPs and most of mine changed status to processed yesterday! I was so excited. And so far none have been denied which I feared.

Unfortunately, at the same time I learned that my OON therapy claims for my DC are only being processed for less than 50% of the fee which is crazy low compared to when we had Cigna. At this rate, we will never hit the OON deductible. Oh well! Can’t win them all.

PP, you seem to be the only here whose OON claims have been processed in 2026. Have you received your reimbursement from CF yet?

[Anonymous]

call first thing in the morning

take notes of the conversation. write down the agent's name.

be prepared to do it again in a week.

i find that persistence always pays with the health insurance company