Carefirst claims not processing

[Anonymous]

Anonymous wrote:All of my OON claims have been processed. I emailed the CEO with a trail of who I talked to and when (and what they said), and the details of each claim.

This is a terrific suggestion - especially the compelling detail of including prior customer service contacts - thank you! If you could share the contact information you used for the CEO that will help us all…

[Anonymous]

Anonymous wrote:This isn't just a problem with OON claims. I have some In Network claims from my colonoscopy back in early January and they are still "in process". They have paid my most recent claims but not the early January colonoscopy claims (high dollar claims). I have emailed customer service several times and they are not responding.

One rep in my calling stated that they were working from most recent to oldest now in an attempt to catch up. I don't know what to believe. We switched to Carefirst from another provider, and I'm also finding that the OON amounts reimbursed are much less than the prior company did. Like an allowed OON amount for therapy is like $90 for a 45 minute session -- but the therapist billed $190. When we brought that up with HR and said that none of it was communicated, they said that the information about what costs are allowable and at what dollar amount are trade secret information.

I very much feel like there is a penalty for using OON providers, which sucks.

[Anonymous]

Anonymous wrote:

Anonymous wrote:All of my OON claims have been processed. I emailed the CEO with a trail of who I talked to and when (and what they said), and the details of each claim.

This is a terrific suggestion - especially the compelling detail of including prior customer service contacts - thank you! If you could share the contact information you used for the CEO that will help us all…

When I emailed, they were in between CEOs. Looks like the new one will be effective May 4th of this year. I don’t feel comfortable putting the CEOs email address on a public forum, but what I will say is that the Carefirst email format is first name dot last name at carefirst dot com. I would assume that the interim CEO is still in place until the new one goes in on May 4th. Google is your friend.

[Anonymous]

Anonymous wrote:

Anonymous wrote:This isn't just a problem with OON claims. I have some In Network claims from my colonoscopy back in early January and they are still "in process". They have paid my most recent claims but not the early January colonoscopy claims (high dollar claims). I have emailed customer service several times and they are not responding.

One rep in my calling stated that they were working from most recent to oldest now in an attempt to catch up. I don't know what to believe. We switched to Carefirst from another provider, and I'm also finding that the OON amounts reimbursed are much less than the prior company did. Like an allowed OON amount for therapy is like $90 for a 45 minute session -- but the therapist billed $190. When we brought that up with HR and said that none of it was communicated, they said that the information about what costs are allowable and at what dollar amount are trade secret information.

I very much feel like there is a penalty for using OON providers, which sucks.

They’re “trade secrets” yet all the insurance companies are illegally sharing those amounts with each other to reduce competition and keep reimbursement down. Google the lawsuit against MultiPlan.

[Anonymous]

Anonymous wrote: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?

If this is an in network provider, just stay out of it. It’s for them to work out with Carefirst. The doctor’s office has a contract with Carefirst. Do not pay the doctor’s office. They shouldn’t even be discussing it with you. Also, if they try to collect from you, that is insurance fraud since they have already filed a claim with Carefirst. DO NOT PAY YOUR IN NETWORK DOCTOR’S OFFICE ANYTHING.

[Anonymous]

It's Carefirst corporate policy to delay, obfuscate, etc. Their customer service people are really nice but they won't be able to help you.

Contact your state commissioner or even your state attorney general's office.

Carefirst wouldn't pay the medical bills, claimed a million reasons why they were not responsible for the bills, and in the end they were sued. That was the only thing that worked.

[Anonymous]

Adding our experience. I can see how carefirst and all insurers are incentivized to delay, deny, etc., especially on expensive out of network treatment. However, that has not been our experience. We have been on an employer sponsored carefirst plan for many years, without incident. This included their sticking with us through some difficult and expensive complex health care. We have never had any issues, until this year. Our in network claims from January first on only started clearing in late March and none of our 2026 out of network claims have been processed. I’ve been told it is a platform transition and integration issue and while I am annoyed by the delayed claims for out of pocket expenses I’m not yet ready to say carefirst is engaged in customer fraud.

[Anonymous]

Anonymous wrote:Adding our experience. I can see how carefirst and all insurers are incentivized to delay, deny, etc., especially on expensive out of network treatment. However, that has not been our experience. We have been on an employer sponsored carefirst plan for many years, without incident. This included their sticking with us through some difficult and expensive complex health care. We have never had any issues, until this year. Our in network claims from January first on only started clearing in late March and none of our 2026 out of network claims have been processed. I’ve been told it is a platform transition and integration issue and while I am annoyed by the delayed claims for out of pocket expenses I’m not yet ready to say carefirst is engaged in customer fraud.

I am the OP and this has been our experience as well. Carefirst has been very reliable for us though some very expensive health issues - hospitalizations, cancer treatments, etc.

Some of my OON claims have now processed but the allowed amounts are much lower than they have been in previous plan years. It appears they are using a different methodology to calculate the allowed amounts. I’m assuming this is an employer choice, but I do plan to appeal to see if I get anywhere. I still have several claims from 2026 that have not processed and a few from the end of 2025.

[Anonymous]

doctors offices are getting mad at me. BCBS didn't send the EOB's to the third party insurance and I'm getting billed even though they didn't do their part in this process. What is going on?

[Anonymous]

Thank you, OP - for this thread and for your update. Any sense as to what triggered your OON claims finally being processed? Calling has not seemed to help as ours are still pending from as early as the start of January. It frustrating, so I’m wondering if you think any specific actions helped in your case.

Anonymous wrote:

Anonymous wrote:Adding our experience. I can see how carefirst and all insurers are incentivized to delay, deny, etc., especially on expensive out of network treatment. However, that has not been our experience. We have been on an employer sponsored carefirst plan for many years, without incident. This included their sticking with us through some difficult and expensive complex health care. We have never had any issues, until this year. Our in network claims from January first on only started clearing in late March and none of our 2026 out of network claims have been processed. I’ve been told it is a platform transition and integration issue and while I am annoyed by the delayed claims for out of pocket expenses I’m not yet ready to say carefirst is engaged in customer fraud.

I am the OP and this has been our experience as well. Carefirst has been very reliable for us though some very expensive health issues - hospitalizations, cancer treatments, etc.

Some of my OON claims have now processed but the allowed amounts are much lower than they have been in previous plan years. It appears they are using a different methodology to calculate the allowed amounts. I’m assuming this is an employer choice, but I do plan to appeal to see if I get anywhere. I still have several claims from 2026 that have not processed and a few from the end of 2025.

[Anonymous]

I reached out to my HR department who eventually submitted an inquiry to Carefirst for me. That may have helped.

[Anonymous]

A couple of years ago when we first joined Carefirst, their reps lied to me for months about my coverage. Literally they would put me on hold for 20-30 minutes to "look into it" and would email me documents that did not pertain to my plan. I sent them a message on the portal and they responded once again with lies, but this time there was a paper trail and I sent that to my HR department. The issue was swiftly resolved after that. I never called Carefirst again. If they are going to lie to me they have to do it in writing.

[Anonymous]

CAN someone please help?! PP here they have still not payed my claim and its gone to collections what am I supposed to do now? I have great credit I do not want to ruin but PP posters said DO NOT PAY the doctors office. So then what am I supposed to do?

[Anonymous]

Anonymous wrote:CAN someone please help?! PP here they have still not payed my claim and its gone to collections what am I supposed to do now? I have great credit I do not want to ruin but PP posters said DO NOT PAY the doctors office. So then what am I supposed to do?

Is this OON or In network? If the latter, submit a claim with the MD AG https://oag.maryland.gov/our-office/Pages/heau.aspx. Notify the organizations billing office that you have submitted a claim to the AG.

[Anonymous]

Anonymous wrote:

Anonymous wrote:CAN someone please help?! PP here they have still not payed my claim and its gone to collections what am I supposed to do now? I have great credit I do not want to ruin but PP posters said DO NOT PAY the doctors office. So then what am I supposed to do?

Is this OON or In network? If the latter, submit a claim with the MD AG https://oag.maryland.gov/our-office/Pages/heau.aspx. Notify the organizations billing office that you have submitted a claim to the AG.

AG or SCC?