Enrollee Notification Form Required for Out-of-network Care

Effective Jan. 1, an out-of-network care form will be required for members enrolled in Blue Choice PPO^SM and Blue Advantage HMO^SM (for Blue Advantage Plus point-of-service benefit plan).

It is essential that Blue Choice PPO and Blue Advantage Plus enrollees fully understand the impact of an out-of-network referral to a provider, hospital, ambulatory surgery center (ASC) or other facility that does not participate in their BCBSTX provider network.

Prior to referring a Blue Choice PPO or Blue Advantage Plus enrollee to an out-of-network provider for non-emergency services, network physicians must complete this form if such services are also available through an in-network provider. The referring network physician must provide a copy of the completed form to the enrollee and retain a copy in his or her medical record files.

Use of this form is subject to periodic audit to determine compliance with this administrative requirement outlined in the provider manuals.