HMO IPA/medical group procedures manual

This manual describes the policies and operating procedures for HMO IPAs and medical groups that contract with Blue Shield of California to provide healthcare services for members of our HMO plans (including our Access+ HMO®, Trio HMO and Blue Shield Medicare Advantage plans). You'll need Adobe Reader to view the manual.

Change notification

April 2024 Provider Manual change notification letter (PDF, 100 KB)

Complete manual

 April 2024 HMO IPA/medical group procedures manual (PDF, 3.3 MB)

Content by section

Section 1: Blue Shield Introduction

• 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)        

Section 2: Benefit plans

• 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)

Section 3: Eligibility

• 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)

Section 4: Contract administration

• Network administration
• Member rights and responsibilities
• Capitation
• Claims administration
• Provider appeals and dispute resolution
• Shared Savings Program

         Download Section 4 (PDF, 620 KB)

Section 5: Medical Care Solutions

• Utilization management
• Quality management programs

         Download Section 5 (PDF, 640 KB)

Section 6: Blue Shield Medicare Advantage Plan

• 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)

Appendices

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)