Independent Physician and Provider Manual

• Purpose of the Independent Physician and Provider 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, 302 KB)

• 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
• Linguistic and Cultural Requirement
• 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)

Download Section 2 (PDF, 483 KB)

• Medical Care Solutions Program Overview
• Medical Necessity
• UM Criteria and Guidelines
• Blue Shield Medical and Medication Policies
• Practice Guidelines
• Use of Free-Standing Urgent Care Centers
• Use of Out of Network Health Care Professionals and Facilities
• Referral to Out of Network Health Care Professionals and Facilities
• 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
• Specialty Drugs

Download Section 3 (PDF, 215 KB)

• 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)

• 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
• Point of Service (POS) Plans
• Federal Employee Program (FEP) (PPO)
• Medicare Supplement Plans
• The BlueCard® Program
• Other Payors
• Mental Health and Substance Use Disorder Services
• Ancillary Benefits
• Care Management
• Home-Based Palliative Care Program
• Wellness and Prevention Programs

Download Section 5 (PDF, 385 KB)

• Overview
• HMO Practitioner Responsibilities
• HMO Member-Related Issues
• Provider Status Changes
• HMO Claims Submissions and Processing

Download Section 6 (PDF, 105 KB)

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)