Provider Manuals

• EPO, PPO, Blue Choice PPO^SM and MyBlue Plus^SM - POS Networks  
• FEP and Custom Networks 
• HMO Networks 
• Government Programs Networks 

The Commercial Provider Manual is organized into the following sections for providers participating in PPO, Blue Choice PPO^SM, HMO and the Blue High Performance Network^® EPO. Click on a section title to view the content.

• Behavioral Health Program 
• Billing and Reimbursement  
  
• Coordinated Home Care 
• Credentialing Standards 
• Durable Medical Equipment 
• Electronic Commerce 
• Extended Care 
• Fraud and Abuse 
• HMO Claims Processing 
• HMO Coordination of Benefits 
• HMO Membership Information 
• HMO Medical Service Agreement Highlight and Process Summary 
• HMO Network Adequacy
• HMO Payment/Compensation to the IPA 
• HMO Scope of Benefits
• HMO Utilization Management Plan 
• Health Care Medical Management (This section includes Utilization Management and Prior Authorization.)
• Home Infusion Therapy 
• Hospice 
• NCQA Accreditation Requirements 
  
• Pharmacy Management 
• Quality Improvement
• Glossary of Terms

HMO Policy and Procedures

Health Care Delivery Policy and Procedures

Blue Cross Community Health Plans Provider Manual

MMAI Provider Manual

• Appointment of Representative
• CMS Qualified Medicare Beneficiary Program
• MA Annual Wellness Visit Form
• MA Annual Wellness Visit Guide
• MA HMO IL Notice of Non-Discrimination Notice
• MA HMO IL Notice of Non-Discrimination Notice (Spanish Version)
• MA HMO Integrated Denial Notice Letter
• MA HMO Integrated Denial Notice Letter (Spanish Version)
• MA HMO Notice of Dismissal of Organization Determination Request
• MA HMO Notice of Dismissal of Organization Determination Request (Spanish Version)
• MA HMO Notice of Medicare Non-Coverage
• MA HMO Notice of Medicare Non-Coverage (Spanish Version)
• MA HMO Medicare Re-opening Letter
• MA HMO Medicare Re-opening Letter (Spanish Version)
• MA HMO Right to Expedited Grievance
• MA HMO Right to Expedited Grievance (Spanish Version)
• MA HMO UM Approval In-network Provider Letter
• MA HMO UM Approval In-network Provider Letter (Spanish Version)
• MA HMO UM Approval Out-of-network Provider Letter
• MA HMO UM Approval Out-of-network Provider Letter (Spanish Version)

The manual is organized into the following sections for your convenience. Click on a section title to view the content.  

• MA HMO Delegated Manual
• MA HMO Policy and Procedure
• MA HMO Utilization Management

Blue Cross Medicare Advantage HMO Non-Delegated Model Manual

Blue Cross Medicare Advantage PPO Provider Manual