March 2018
Correction to HMO Plans – PCP Selection and Referral Requirements
Blue Cross and Blue Shield of Texas (BCBSTX) HMO plans are:
- Blue Advantage HMOSM
- Blue Advantage PlusSM
- Blue EssentialsSM
- Blue Essentials AccessSM
- Blue PremierSM
- Blue Premier AccessSM
Corrections to clarify Blue Advantage Plus HMO and Blue Essentials Access are bolded in the table below.
Blue Advantage Plus, Blue Essentials Access and Blue Premier Access are considered “open access” HMO plans where no Primary Care Provider (PCP) selection or referrals are required when the member uses participating providers in their network.
For Blue Advantage HMO, Blue Essentials and Blue Premier where referrals are required, it must be initiated by the member's designated PCP and must be made to a participating physician or professional provider in the same provider network.
The table defines when a PCP and referrals to specialists (except OB-GYN) are required and when they are not required. (Note: Members can self-refer to in-network OB/GYNs – no referrals are required.) If an in-network physician, professional provider, ambulatory surgery center, hospital or other facility is not available in the member's applicable provider network, preauthorization is required for services by an out-of-network physician, professional provider, ambulatory surgery center, hospital or other facility, through either iExchange® or by calling the preauthorization number on the back of the member ID card.
Additional services for all HMO plans may require preauthorization. A complete list of services that require preauthorization or a referral for in and out of network benefits is available on the BCBSTX provider website under Clinical Resources/Preauthorization/Notification/Referral Requirements.
| HMO Plan | Designated PCP Required | Referrals Required for In-Network Providers | *Out-Of-Network Benefits Available with Higher Member Cost Share |
| Blue Advantage HMO | Yes | Yes | No |
| Blue Advantage Plus HMO | Yes | Yes | Yes |
| Blue Essentials | Yes | Yes | No |
| Blue Essentials Access | No | No | No |
| Blue Premier | Yes | Yes | No |
| Blue Premier Access | No | No | No |
*Prior to referring a Blue Advantage Plus HMO member to an out-of-network provider for non-emergency services, please refer to 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.
Blue Advantage HMO, Blue Advantage Plus, Blue Essentials and Blue Premier where referrals are required, it must be initiated by the member's designated PCP and must be made to a participating physician or professional provider in the same provider network.
Blue Essentials Access and Blue Premier Access are considered “open access” HMO plans where no Primary Care Provider (PCP) selection or referrals are required when the member uses participating providers in their network.
Sample HMO ID cards and other benefit plan ID cards are available on the BCBSTX provider website.
Reminders:
- The Blue Essentials, Blue Advantage HMO and Blue Premier physician, professional provider, facility or ancillary providers are required to admit a patient to a participating facility, except in emergencies.
- Blue Advantage Plus is a benefit plan that allows members to use out-of-network providers. However, members must understand the financial impact of receiving services from an out-of-network physician, professional provider, ambulatory surgery center, hospital or other facility.
PleaseTM note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits 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 and the terms of the member's certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member's ID card.
iExchange is a trademark 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 third-party vendors such as Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.