Hospital and Facility Guidelines Manual

• 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)

• 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

Download Section 2 (PDF, 547 KB)

• 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)

• 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)

• 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)

• 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)

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)