May 2021

Enrollee Notification Form Required for Out-of-Network Care for Blue Choice PPO^SM and Blue Advantage HMO^SM (for Blue Advantage Plus^SM)

Prior to referring a Blue Choice PPO or Blue Advantage HMO (for Blue Advantage Plus point-of- service benefit plan) member to an out-of-network provider for non-emergency services – if such services are also available through an in-network provider – the referring participating network provider must complete the appropriate Out-of-Network Care – Enrollee Notification forms for Regulated Business (used when “TDI is on the member’s ID Card) or Non-Regulated Business (No “TDI on member’s ID card). You can locate the forms under Forms on the BCBSTX provider website. 

The referring network physician must provide a copy of the completed form to the enrollee and retain a copy in the enrollee’s medical record files. 

It is essential that Blue Choice PPO and Blue Advantage Plus enrollees fully understand the financial impact of an out-of-network referral to a health care provider that does not participate in their BCBSTX provider network. They have out-of-network benefits and may choose to use out-of- network providers, however they will be responsible for an increased cost-share under their out-of-network benefits.