Hospital and Facility Guidelines Manual

These guidelines describe policies and administrative procedures for Blue Shield network hospitals and facilities, including ambulatory surgery centers, behavioral health outpatient facilities, birthing centers, dialysis centers, residential treatment centers, and skilled nursing facilities. You'll need Adobe Reader to view the manual.

Change notification

January 2020 Provider Manual change notification letter (PDF, 168 KB)

Complete manual

January 2020 Hospital and Facility Guidelines (PDF, 4.9 MB)

Content by section

  • Section 1: Introduction
    • Purpose of the Hospital and Facility Guidelines Manual
    • Enrollment and Eligibility
    • Member Rights and Responsibilities
    • Member Grievance Process
    • Fraud Prevention
    • Blue Shield's Code of Conduct and the Corporate Compliance Program
    • Blue Shield Medicare Advantage Program Overview
    • Blue Shield Medicare Advantage Compliance Program
    • Healthcare Regulatory Agencies

    Download Section 1 (PDF, 276 KB)

  • Section 2: Hospital Responsibilities
    • Quality Management and Improvement
    • Service Accessibility Standards
    • After-Hours Requirements for Commercial and Medicare Members
    • Provider Availability Standards for Commercial Products
    • Provider Availability Standards for Medicare Advantage Products
    • Language Assistance for Persons with Limited English Proficiency (LEP)
    • Use of Non-Preferred/Non-Participating Providers
    • Facility Directory

    Download Section 2 (PDF, 547 KB)

  • Section 3: Medical Care Solutions
    • Medical Care Solutions Program Overview
    • Admission Authorization
    • Organ and Bone Marrow Transplants
    • Admission and Concurrent Inpatient Review
    • Medical Necessity Denials
    • Quality-of-care Assessment
    • Continuity of Care for Members by Non-contracted Providers
    • Blue Shield Medical and Medication Policies

    Download Section 3 (PDF, 266 KB)

  • Section 4: Billing and Payment
    • Claims Submission
    • Claim Attachments
    • Claims Processing Logic and Payment Policies
    • Special Billing Situations
    • Where to Send Claims
    • BlueCard Program Claims
    • Facility Compliance Review (FCR)
    • Incidental Procedures
    • Hospital-Acquired Conditions / Never Events
    • Blue Shield Explanation of Payments (EOP)
    • Third Party Liability (TPL)
    • Coordination of Benefits (COB)
    • Limitations for Duplicate Coverage (Commercial)
    • Transition of Care / Financial Responsibility Upon Enrollment/Disenrollment for Medicare Advantage Members
    • Claim Inquiries and Adjustments
    • Timely Submission of Claims and Appeals
    • Provider Inquiries
    • Provider Appeals and Dispute Resolution
    • Capitated Entity (IPA/MG/Capitated Hospitals) Appeal Resolution Requirements
    • Provider Appeals of Medicare Advantage Claims

    Download Section 4 (PDF, 594 KB)

  • Section 5: Blue Shield Benefit Plans and Programs
    • Blue Shield HMO Plans
    • Blue Shield Medicare Advantage Plans
    • Medicare Part D
    • Blue Shield PPO Plans
    • Blue Shield Medicare (PPO) (Medicare Advantage)
    • National Medicare Coverage Determinations 
    • Blue Shield Point of Service (POS) Plans
    • Federal Employee Program (FEP)
    • Medicare Supplement Plans
    • The BlueCard Program
    • Other Payors
    • Care Management
    • Wellness and Prevention Programs

    Download Section 5 (PDF, 513 KB)

  • Section 6: Capitated Hospital Requirements
    • Overview
    • Monthly Eligibility Reports
    • Capitation
    • Capitated Services Claims Processing
    • Encounter Data Submission

    Download Section 6 (PDF, 245 KB)

  • Appendices

    Appendix for Section 1 (PDF, 271 KB)

    This manual does not contain an Appendix for Section 2

    This manual does not contain an Appendix for Section 3

    Appendix for Section 4 (PDF, 785 KB)

    Appendix for Section 5 (PDF, 1.4 MB)

    Appendix for Section 6 (PDF, 552 KB)

Forms

Download and print commonly requested patient care, prior authorization and network forms.

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Guidelines and procedures

Find operating guidelines for clinical practices, preventive health and procedures for continuing network participation.

Read guidelines

Policies and standards

Find medication policies information and standards for HIPAA transactions, medical records and more.

Read about our policies and standards

Drugs and pharmacy resources

Search our drug formulary database, find prior authorization forms and procedures for different types of prescriptions, learn about our mail service pharmacy for medication delivery and find out about generic alternatives.

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