September 2023
Enrollee Notification Form Required for Out-of-Network Care for Blue Choice PPOSM and Blue Advantage HMOSM (for Blue Advantage Plus)
Prior to referring a Blue Choice PPO or Blue Advantage HMO member (for Blue Advantage Plus point-of-service benefit plan) to an out-of-network provider for non-emergency services (when such services are 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). Locate them under Forms on our provider website.
Also, 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.