Enrollee Notification Form Required for Out-of-Network Care for Blue Choice PPOSM and Blue Advantage HMOSM (for Blue Advantage PlusSM)
Before 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 a member’s ID Card) or Non-Regulated Business (used when “TDI” is not on a member’s ID card). Locate them under Forms on our 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. Although they have out-of-network benefits and may use out-of-network providers, they will be responsible for an increased cost-share under their out-of-network benefits.