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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.

Content by section

  • Section 1: Introduction
    • Purpose of the Hospital and Facility Guidelines Manual
    • Enrollment and Eligibility
    • Member Rights and Responsibilities - Blue Shield HMO and PPO Commercial Members
    • Member Rights and Responsibilities - Blue Shield Medicare 65 Plus Members
    • 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, 281 KB)

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

    Download Section 2 (PDF, 547 KB)

  • Section 3: Medical Care Solutions
    • Medical Care Solutions Program Overview
    • Medical Necessity
    • UM Criteria and Guidelines
    • Medical Necessity Denials
    • Blue Shield Medical and Medication Policies
    • Admission Authorization
    • Organ and Bone Marrow Transplants
    • Admission and Concurrent Inpatient Review
    • Subacute Level of Care Criteria
    • Continuity of Care for Members by Non-Contracted Providers

    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
    • Confidentiality of Substance Use Disorder Patient Records

    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)


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