The Blue Medicare PPO plan follows the same coverage policies of the Centers for Medicare & Medicaid Services (CMS).  The policies are posted on the CMS Web site.  CMS wants to ensure providers and health care practitioners have quick access to accurate Medicare program information.  In keeping with this goal, the provider specific pages are a one-stop resource focused on the information needs and interests of Medicare providers, including physicians and other practitioners.  Access the CMS site here.

This program does not have a "gate keeper" and the member can see a specialist without a referral from a primary care physician.  There are situations that will require a preauthorization.  These are specifically addressed on the Precertification Requirements List.

Your Medicare Advantage (MA) amendment states the following, "Provider shall furnish Covered Services to MA Subscribers in a manner consistent with the requirements of the Medicare statutes, regulations, CMS pronouncements and BCBSTX policies, as well as professionally recognized standards of health care."  Click here to obtain more information.