Hospital and facility guidelines manual
These guidelines describe policies and administrative procedures for Blue Shield network hospitals and facilities, including ambulatory surgery centers, behavioral health outpatient facilities, birthing centers, dialysis centers, residential treatment centers, and skilled nursing facilities. You'll need Adobe Reader to view the manual.
Change notification
January 31, 2024 Provider Manual change notification letter (PDF, 100 KB)
Complete manual
January 31, 2024 hospital and facility guidelines (PDF, 4.6 MB)
Content by section
Section 1: Introduction
- 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)
Section 2: Hospital responsibilities
- 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
- Health information data and record sharing with Blue Shield
- Download Section 2 (PDF, 547 KB)
Section 3: Medical Care Solutions
- 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)
Section 4: Billing and payment
- 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)
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
- Care management
- Wellness and prevention programs
- Download Section 5 (PDF, 513 KB)
Section 6: Capitated hospital requirements
- 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)
Appendices
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)
Forms
Download and print commonly requested patient care, prior authorization and network forms.
Guidelines and procedures
Find operating guidelines for clinical practices, preventive health and procedures for continuing network participation.
Policies and standards
Find medication policies information and standards for HIPAA transactions, medical records and more.
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.