April 2019

BCBSTX Plans and Referral Requirements

Blue Cross and Blue Shield of Texas (BCBSTX) has the following PPO and HMO plans:

Blue Choice PPO^SM
Covered members have direct access to all in-network Blue Choice PPO providers. A covered person does not need to obtain a referral from their primary care physician (PCP) to seek services/care from an in-network specialty care physician or provider. Covered persons can choose to use out-of-network providers under their out-of-network benefit. If an out-of-network provider, including facilities, are necessary due to network inadequacy or continuity of care, then authorization is required by BCBSTX.

HMO Plans

• Blue Advantage HMO^SM
• Blue Advantage Plus^SM*
• Blue Essentials^SM
• Blue Essentials Access^SM*
• Blue Premier^SM
• Blue Premier Access^SM*

Blue Advantage HMO, Blue Essentials and Blue Premier require referrals initiated by the covered person's designated PCP and must be made to an in-network physician or professional provider in the covered person’s applicable HMO provider network. Blue Essentials, Blue Advantage HMO and Blue Premier physicians and professional providers are required to admit a patient to an in-network facility in the covered person’s HMO provider network, except in an emergency.

*Note:

• Blue Essentials Access and Blue Premier Access are considered “open access” HMO plans where no PCP selection or referrals are required when the covered person uses in-network providers in their applicable HMO network.
• Blue Advantage Plus allows covered persons to use out-of-network providers. Covered persons can choose to self-direct their care under their out-of-network benefit at a higher out-of-pocket cost. Please be sure the covered person understands the financial impact of receiving services from an out-of-network provider, including facilities.

The table below defines when PCP selection and referrals to specialists are required and if out-of-network benefits are available for the HMO plans.

• Exception: No referrals are required for in-network OB/GYNs in the covered person’s applicable HMO network.
• When in-network providers and/or facilities are not available in the covered person's applicable HMO network, preauthorization would be required to utilize an out-of-network provider and/or facility.

**Before referring Blue Advantage Plus covered persons to an out-of-network provider for non-emergency services, please refer to the Section D Referral Notification Program of the Blue Essentials, Blue Advantage HMO and Blue Premier Provider Manual for more detail (including when to utilize the Out-of-Network Enrollee Notification forms for Regulated Business and Non-regulated Business).

• Some services in both HMO and PPO plans may require preauthorization or prenotification.
• It is imperative that providers use Availity^® or their preferred vendor to obtain eligibility and benefits, determine if you are in- or out-of-network for their plan, and whether preauthorization/prenotification is required. Availity allows preauthorization determination by procedure code. Refer to the BCBSTX Eligibility and Benefits web page for more information on Availity.
• Utilize iExchange^® or call the preauthorization number on the back of the covered person’s identification (ID) card to obtain authorization.
• Sample ID cards are available on the BCBSTX provider website.

Verification of eligibility and/or benefits information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third-party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.

Aerial, iExchange and Medecision^® are trademarks of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity or Medecision. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.