HMO Plans - Importance of Obtaining a Referral and/or Preauthorization and Admitting to a Participating Facility as a Network Provider

HMO Blue Texas^SM, Blue Advantage HMO^SM and Blue Premier^SM members require a referral from their PCP before receiving services from a specialty care physician or professional provider (except for OBGYNs). The referral must be initiated by the member's PCP, and must be made to a participating physician or professional provider in the same provider network.

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 iExchange or call the preauthorization number 1-855-462-1785. 

Reminders:

• The HMO Blue Texas, Blue Advantage HMO and Blue Premier physician, professional provider, facility or ancillary provider is required to admit the patient to a participating facility, except in emergencies.
• Additional services may also require preauthorization. A complete list of services that require preauthorization for HMO Blue Texas and Blue Advantage HMO, and for Blue Premier and Blue Premier Access^SM, is available on the BCBSTX Provider website.  Under the “Standards and Requirements” tab, click on General Reimbursements  (password is “manual”) and scroll down to the “Preauthorization/Notification/Referral Requirements Lists.”
• Blue Advantage Plus^SM HMO Point of Service (POS) is a benefit plan that allows those members to use out-of-network providers. However, it is essential that those members understand the financial impact of receiving services from an out-of-network physician, professional provider, ambulatory surgery center, hospital or other facility. Prior to referring a Blue Advantage Plus enrollee to an out of network provider for non-emergency services, please refer to Section D Referral Notification Program, of the HMO Blue Texas, Blue Advantage HMO and Blue Premier Provider Manual for more detail including when to utilize the Out-of-Network Enrollee Notification Form under the section titled Blue Advantage Plus Out Of Network Only.