Independent Physician and Provider Manual

This manual describes administrative guidelines, policies, and procedures for direct-contact Blue Shield network providers of healthcare services for members of our health plans. You'll need Adobe Reader to view the manual.

Content by section

  • Section 1: Introduction
    • Purpose of the Independent Physician and Provider 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 65 Plus Program Overview
    • Blue Shield 65 Plus Compliance Program
    • Healthcare Regulatory Agencies

    Download Section 1 (PDF, 216 KB)

  • Section 2: Provider Responsibilities
    • General Blue Shield Agreement Terms and Conditions
    • Blue Shield Provider Standards
    • Administrative Compliance
    • Provider Certification
    • Credentialing and Recredentialing
    • Clinical Laboratory Improvement Amendments (CLIA) Program Requirements
    • Medical Record Review
    • Quality Management and Improvement
    • Home-Based Palliative Care Program Providers
    • Submission of Laboratory Results Data
    • Service Accessibility Standards
    • After-Hours Requirements
    • Provider Availability Standards for Commercial Products
    • Provider Availability Standards for Medicare Advantage Products
    • Behavioral Health Requirements - FEP PPO and ASO
    • Linguistic and Cultural Requirement
    • Additional Measurements for Multidimensional Analysis
    • Language Assistance for Persons with Limited English Proficiency (LEP)

    Download Section 2 (PDF, 483 KB)

  • Section 3: Medical Care Solutions
    • Medical Care Solutions Program Overview
    • Practice Guidelines
    • Mental Health and Substance Abuse Clinical Management Program for Self-Insured Accounts (ASO)
    • Blue Shield Medical and Medication Policies
    • Use of Free-Standing Urgent Care Centers
    • Use of Non-Preferred/Non-Participating Providers
    • Referral to Non-Preferred/Non-Participating Providers
    • Billing Members for Durable Medical Equipment (DME)
    • Continuity of Care for Members by Non-Contracted Providers
    • Prior Authorizations
    • Prior Authorization List for Network Providers
    • Organ and Bone Marrow Transplants
    • Drug Formulary

    Download Section 3 (PDF, 207 KB)

  • Section 4: Billing
    • Overview
    • Claims Processing
    • Claims Review Monitoring Program
    • Provider Payment
    • Electronic Remittance Advice (ERA)
    • Third Party Liability (TPL)
    • Coordination of Benefits (COB)
    • BlueCard® Program Claims
    • Limitations for Duplicate Coverage (Commercial)
    • Special Billing Situations
    • Claims Inquiries and Corrected Billings
    • Provider Inquiries
    • Provider Appeals and Dispute Resolution
    • Capitated Entity (IPA/MG/Capitated Hospital) Appeal Resolution Requirements
    • Provider Appeals of Medicare Advantage Claims

    Download Section 4 (PDF, 260 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
    • Mental Health Services
    • Care Management
    • Home-Based Palliative Care Program
    • Wellness and Prevention Programs

    Download Section 5 (PDF, 301 KB)

  • Section 6: Supplemental Direct Contracting HMO Administrative Procedures and Responsibilities
    • Overview
    • HMO Practitioner Responsibilities
    • HMO Member-Related Issues
    • Provider Status Changes
    • HMO Claims Submissions and Processing

    Download Section 6 (PDF, 105 KB)

  • Appendices

    Appendix for Section 1 (PDF, 172 KB)

    Appendix for Section 2 (PDF, 596 KB)

    This manual does not contain an Appendix for Section 3

    Appendix for Section 4 (PDF, 422 KB)

    Appendix for Section 5 (PDF, 1.5 MB)

    Appendix for Section 6 (PDF, 163 KB)

Forms

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

Find forms for Blue Shield of California providers

Find forms for Blue Shield Promise providers

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.

Find pharmacy resources