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

Before referring a Blue Choice PPO or Blue Advantage HMO (for Blue Advantage Plus HMO point-of-service benefit plan) member to an out-of-network provider for non-emergency services, when 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 (when TDI is on the member’s ID card) or Non-Regulated Business (no TDI on member’s ID card). The forms are on our provider website.

Note: Referring network physicians must provide a copy of the completed form to enrollees and retain a copy in their medical record files. 

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

Clinical Payment and Coding Policy Updates

Our website’s Clinical Payment and Coding Policies describe payment rules and methodologies for CPT, HCPCS and ICD-10 coding for claims submitted as covered services. This information is a resource for our payment policies and does not address all reimbursement-related issues. We may add and modify clinical payment and coding policies. The following policies were added or updated:

• CPCP025 Corrected Claim Submission Updated Including Changes for Late/Added Charges
• CPCP006 Preventive Services Policy Update – Effective 04/01/2024
• CPCP028 Non-Reimbursable, Experimental, Investigational and/or Unproven Services (EIU) Updated Versions – Effective 04/01/2024 & 05/15/2024
• CPCP028 Non-Reimbursable, Experimental, Investigational and/or Unproven Services (EIU) Updates – Effective 07/01/2024