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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 - 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, 297 KB)

  • Section 2: Provider Responsibilities
    • General Blue Shield Agreement Terms and Conditions
    • Blue Shield Provider Standards
    • Administrative Compliance
    • Provider Certification
    • Provider Directory
    • 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)
    • Health Information Data and Record Sharing with Blue Shield

    Download Section 2 (PDF, 525 KB)

  • Section 3: Medical Care Solutions
    • 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

    Download Section 3 (PDF, 232 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, 317 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
    • 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, 376 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, 89 KB)

  • Appendices

    Appendix for Section 1 (PDF, 340 KB)

    Appendix for Section 2 (PDF, 524 KB)

    There is no appendix for Section 3.

    Appendix for Section 4 (PDF, 580 KB)

    Appendix for Section 5 (PDF, 1.4 MB)

    Appendix for Section 6 (PDF, 186 KB)


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.

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Policies and standards

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

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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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