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Blue EssentialsSM (formerly known as HMO Blue TexasSM), Blue Advantage HMOSM, Blue PremierSM Physician, Professional Provider, Facility and Ancillary Provider Online Orientation Check List

  1. Blue EssentialsSM (formerly known as HMO Blue TexasSM), Blue Advantage HMOSM, Blue PremierSM Physicians, Professional Providers, Facility and Ancillary Providers — Provider Manual — is located under the Standards and Requirements tab, go to General Reimbursement Information (password protected-enter password), then under Manuals, click on View Manuals and then select the Blue EssentialsSM (formerly known as HMO Blue TexasSM), Blue Advantage HMOSM, Blue PremierSM Physician, Professional Provider, Facility and Ancillary Provider — Provider Manual.
    • Limited Provider Networks — if applicable (Section A)
    • ID Cards can be found in Section B of the manual and on website under ID Card Samples: Standard Group HMO/PPO and Standard Individual HMO/PPO
    • PORG - location on ID Card
    • Physician, Professional Provider, Facility and Ancillary Provider Roles and Responsibilities (Section B)
    • Referrals Required (Section B)
    • Filing Claims (Section F)
    • Provider Customer Service — 800-451-0287
  2. Blue Essentials, Blue Advantage HMO, or Blue Premier Quick Reference Guides (QRG) — under the Education and Reference tab, go to the Related Resources area, click on Reference Guides, then click on Product and Group Specific Reference Guides, and finally, click on the Blue Essentials, Blue Advantage HMO, or Blue Premier Quick Reference Guide.
    • Review each column of the Quick Reference Guide:
      • Major Characteristics
      • Benefits, Eligibility, Claims Status and Verification
      • Correspondence, Claim Review Process
      • Preauthorization/Notification/Referral Requirements — under the the Clinical Resources menu then Preauthorizations/Notifications/Referral Requirements Lists — and select Blue Essentials, Blue Advantage HMO, or Blue Premier list.
      • Laboratory Services
      • Behavioral Health
  3. iExchange — Preauthorization and Online Approval of Benefits for Selected Outpatient Services and Inpatient Admissions
  4. Laboratory Services — Go to the Standards and Requirements tab, then go to General Reimbursement Information (password protected-enter password), then under Manuals, click on View Manuals and then select the Blue EssentialsSM (formerly known as HMO Blue TexasSM), Blue Advantage HMOSM, Blue PremierSM Physician, Professional Provider, Facility and Ancillary Provider — Provider Manual., then select Section B.
    • Quest Diagnostics, Inc. is the exclusive outpatient clinical reference laboratory for Blue Essentials.
    • Reimbursable Lab Services List — if performed in the provider's office
  5. Filing Claims — Go to the Standards and Requirements tab, then go to General Reimbursement Information (password protected-enter password), then under Manuals, click on View Manuals and then select the Blue EssentialsSM (formerly known as HMO Blue TexasSM), Blue Advantage HMOSM, Blue PremierSM Physician, Professional Provider, Facility and Ancillary Provider — Provider Manual., then select Section F.
  6. Filing Claims — For OBGyn Physicians
  7. Pharmacy — Specialty Pharmacy Programs
    • Go to the Pharmacy Program tab, then go to the "Prime Specialty Pharmacy " offering
  8. Blue Essentials, Blue Advantage HMO, and Blue Premier Provider Directory
    • Go to the Network Participation tab, then go to the Provider Finder offering
  9. Changes Affecting Your Provider Record ID, Change in Your Status or Changes Affecting Your NPI Number, Added a New Office Location, Moved to a New Office Location?

    Call 972- 996-9610, press 3 or go to the Network Participation tab, then go to the Update Your Information offering, complete and submit the online form or print and fax it to the indicated number.

  10. Review of the BCBSTX Provider Website
    • Home Page
      • National Drug Codes (NDCs) Billing Resources
      • Electronic Commerce
      • Blue Cross Medicare Advantage PPO
      • Blue Cross Medicare Advantage HMO
      • Blue Cross Medicare Advantage Dual Care (HMO SNP)
      • Medicaid (STAR) and CHIP
      • Medical Policies
    • Network Participation
      • How to Join BCBSTX Provider Networks
      • Update Your Information
      • Provider Finder
      • Consent to Assignment of Provider Contracts (Change of Ownership — CHOW) for Facility/Ancillary
    • Claims and Eligibility
      • BlueCard Program
      • Claim Filing Tips
      • Claims Review Process
      • Claim Status
      • Electronic Commerce
      • How to Check Claim Status
      • IVR System
      • Medicare Advantage Private Fee-for-Service Router
      • Physicians’ Advisory Committee (PAC)
    • Education and Reference Center
      • Forms – Go through FORMS documents
      • Identification Cards
      • News and Updates
      • Provider Tools
      • Training
    • Clinical Resources
      • Behavioral Health
      • Clinical Practice Guidelines (CPGs)
      • Clotting Factor Product Initiative
      • e-Cards for Health
      • eviCore Preauthorization Program
      • iExchange — Automated Preauthorization and Referral System
      • Preauthorizations/Notifications/Referral Lists
      • Pre-cert/Pre-auth Router (for out-of-area members)
      • Radiology Quality Initiative Program
      • Special Beginnings – A Maternity Program
      • Wellness Initiatives/Programs
      • Preventive Care Guidelines/Patient Wellness Guidelines
    • Pharmacy Program
      • Dispensing Limits
      • Medicare Part D Pharmacy Updates
      • Prescription Drug List and Prescribing Guidelines
      • Specialty Drug Programs
      • Split Fill Program
      • Prior Authorization and Step Therapy
    • Standards and Requirements
      • Affordable Care Act
      • ANSI 5010
      • Clinical Payment and Coding Policies
      • Disclosure Notices
      • Draft Medical Policies
      • General Reimbursement Information
      • Manuals
      • ICD-10
      • Medical Policies
      • Medical Policy and Pre-certification/Pre-authorization Router for Out-of-Area Members
  11. Review of the Secured Area of the BCBSTX Provider Website (password protected-enter password)
    • Manuals
    • Medical Policy Request Form
    • Preauthorization/Notification/Referral Requirements Lists
    • Recoupments and Refunds
    • Reimbursement Schedules and Related Information
    • Bundling Information
    • All Product News
    • Blue Essentials — Outpatient Clinical Reference Lab Services
    • Member Liability Estimate