It is essential that Blue Cross and Blue Shield of Texas PPO and POS enrollees fully understand the benefits impact of using a hospital, ambulatory surgery center (ASC), or other facility that does not have a contractual relationship with BCBSTX. 

The Facility Out-of-Network Care Enrollee Notification Form must be completed by a network physician when presenting an out-of-network provider option for future treatment to a BCBSTX PPO or POS enrollee if such services are also available through a BCBSTX in-network provider.  The network physician must provide a copy of the completed form to the enrollee, and should also maintain a copy of the form in his or her records.  The Facility Out-of-Network Care Enrollee Notification Form is posted in the Forms section of the provider portal on our Web site at www.bcbstx.com/provider.  Use of this form will be implemented effective June 1, 2009 in Harris County.

View the Facility Out-of-Network Care Enrollee Notification Form

If the reason for using an out-of-network provider is lack of availability/accessibility of in-network providers, you may request authorization for the service to be reimbursed at the in-network benefit level.  This request must be made prior to services being rendered by contacting the Utilization Management Department at the phone number listed on the back of the member identification card.

revised 07/2009