HMO IPA/Medical Group Procedures Manual

• Purpose and Organization of the Manual
• Fraud Prevention
• Blue Shield's Code of Conduct and the Corporate Compliance Program

Download Section 1 (PDF, 79 KB)

• Blue Shield HMO Benefit Plans
• Access+ HMO Program
• Blue Shield Accountable Care Organizations (ACOs)
• Blue Shield Added Advantage^SM POS (Point of Service) Plan
• Ancillary Benefits
• Exclusions and Limitations
• Benefit Administration
• Benefits and Benefit Programs

Download Section 2 (PDF, 383 KB)

• Introduction
• Initial Enrollment
• Member Eligibility and Coverage
• Member Identification (ID) Cards
• Enrollment Changes
• Eligibility Verification
• Member Primary Care Physician Selection, Assignment and Change
• Provider Requests to Transfer or Disenroll Members

Download Section 3 (PDF, 142 KB)

• Network Administration
• Member Rights and Responsibilities
• Capitation
• Claims Administration
• Provider Appeals and Dispute Resolution
• Shared Savings Program

Download Section 4 (PDF, 620 KB)

• Utilization Management
• Quality Management Programs

Download Section 5 (PDF, 640 KB)

• Blue Shield Medicare Advantage Plan Program Overview
• Blue Shield Medicare Advantage Plan Benefits and Exclusions
• Blue Shield Medicare Advantage Plan Enrollment and Eligibility
• Blue Shield Medicare Advantage Plan Network Administration
• Blue Shield Medicare Advantage Plan Medical Care Solutions
• Blue Shield Medicare Advantage Plan Member Rights and Responsibilities

Download Section 6 (PDF, 597 KB)

Appendix for Section 1 (PDF, 188 KB)

This manual does not contain an Appendix for Section 2

Appendix for Section 3 (PDF, 145 KB)

Appendix for Section 4 (PDF, 510 KB)

Appendix for Section 5 (PDF, 359 KB)

Appendix for Section 6 (PDF, 230 KB)