06/21/22
As a participating provider in Blue Cross and Blue Shield of Texas (BCBSTX) provider networks, you have certain rights and responsibilities noted below that may affect your practice. Your patients also have rights and responsibilities.
Provider rights include:
Your Credentialing Rights
If you are applying or reapplying to participate in our networks, you have the right to:
- Review information submitted to support your credentialing application
- Correct wrong and/or conflicting information
- Receive the status of your credentialing or recredentialing application upon request
To learn more about these rights: Visit the Credentialing page on our Provider website.
Provider responsibilities include:
Case Management Programs
You can help our members maintain or improve their health by encouraging them to participate in relevant case management programs. These may include:
- Condition management programs to support members with specific conditions like asthma or diabetes
- Complex case management services for members facing multiple or complicated medical or behavioral health conditions
- Programs to help members transition home after a hospital stay or navigate the health care system
- Wellness and prevention programs for members of all ages
Members can access applicable services for complex and condition case management by:
- Asking to enroll, or having their caregiver ask to enroll
- Referral from a primary care physician, practitioner, hospital, or other discharge planner
- Referral through utilization management programs
To refer members to any case management programs: Call the number on the members’ ID card. Our clinicians will collaborate with you to provide our members with available resources and additional support.
Utilization Management Decisions
It is BCBSTX’s policy that licensed clinical personnel make all utilization management decisions according to the benefit coverage of a member’s health plan, evidence-based medical policies and medical necessity criteria. Decisions are based on appropriateness of care and service and existence of coverage.
BCBSTX prohibits decisions based on financial incentives. We do not reward practitioners or clinicians for issuing denials of coverage. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization.
To obtain the criteria used for utilization management decisions: Call the number on the members’ ID card. You can also refer to BCBSTX’s medical policies, which are available for review online.
Blue Cross and Blue Shield Federal Employee Program® (FEP®) members: In addition to the details provided above, visit FEP for more information about our FEP members. Call 1-800-441-9188 for questions regarding FEP prior authorizations. For FEP expedited appeals only, the fax number is 972-766-9776.
Member Rights and Responsibilities
Also, as a participating provider we are informing you of members’ rights and responsibilities summarized below:
Member rights include the right to:
- Receive information about Blue Cross and Blue Shield of Texas (BCBSTX), our services, participating providers and facilities, and member rights and responsibilities
- Be treated with respect and dignity with recognition of their right to privacy
- Participate with providers in making decisions about their health care
- Have a candid discussion of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage
- Voice complaints or appeals about BCBSTX or the services we provide
- Make recommendations regarding our members’ rights and responsibilities policy
Member responsibilities include a responsibility to:
- Provide, to the extent possible, information that BCBSTX and the provider and facility need to provide care
- Follow the plans and instructions for care that the member has agreed to with their provider
- Understand their health problems and participate in the development of mutually agreed upon treatment goals, to the degree possible
To learn more about member rights and responsibilities you may refer to:
- Blue Choice PPO℠ and Blue High Performance Network℠ (Blue HPN℠) Provider Manual
- Blue Essentials℠, Blue Advantage HMO℠, Blue Premier℠ and MyBlue Health℠
- Members’ benefit booklet
- Member website, which includes HIPAA NOTICE OF PRIVACY PRACTICE
Texas Medicaid members: In addition to the details provided above, our Medicaid members have an expanded list of rights and responsibilities that can be found here and also in the STAR and CHIP provider manuals (Chapter 13) and STAR Kids provider manual (Chapter 12).