Provider Rights and Responsibilities


Provider Rights and Responsibilities

As a participating provider in our provider networks, you have certain rights and responsibilities that may affect your practice. Some of these are noted below. We publish this information for providers annually.

Your Credentialing Rights

If you’re applying or reapplying to participate in our networks, you have the right to:

  • Review information submitted to support your credentialing application
  • Update incorrect 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.

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 member’s ID card. Our clinicians will collaborate with you to provide our members with available resources and additional support.

Utilization Management Decisions

It’s 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.  

To obtain the criteria used for utilization management decisions: Call the number on the member’s ID card. You can also refer to BCBSTX’s medical policies, which are available for review online.

Learn more about Utilization Management on our provider website.

Blue Cross and Blue Shield Federal Employee Program® members: In addition to the details provided above, visit for more information about our FEP® members. Call 800-441-9188 for questions regarding FEP prior authorizations. For FEP expedited appeals only, the fax number is 972-766-9776.