Blue Essentials ^SM, Blue Advantage HMO^SM, Blue Premier^SM and MyBlue Health^SM - Provider Manual

Please access the latest version of the Blue Essentials^SM, Blue Advantage HMO^SM, Blue Premier^SM and MyBlue Health Provider Manual below. This manual was developed to provide you and your staff with administrative guidelines with respect to the Blue Essentials, Blue Advantage HMO, Blue Premier and MyBlue Health Networks.

You can view and print content by section. This manual will be updated, as needed, and these updates will be posted to this site. These files are in a PDF format and require Adobe Reader to open and view them.

If you have trouble opening the files or accessing the information, please contact your Network Management office for additional options in receiving the latest version of this manual.

Blue Essentials, Blue Advantage HMO, Blue Premier and MyBlue Health Download Section

Cover Page

Table of Contents

A. Support Services

B. Provider Roles and Responsibilities –   (a) Network and ID Cards     (b) Eligibility and Benefits    (c) Roles and Responsibilities    (d) Outpatient Lab and Radiology Guidelines    (e) How to Join    (f)  Credentialing

C. Authorization Process

D. Referral Notification Program

E. Prior Authorization and Case Management

F. Filing Claims –   (a) General Information    (b) Prompt Pay    (c) Billing Requirements    (d) Claim Forms    (e) Electronic Filing    (f)  Ancillary Services    (g) Facility Services    (h) Claim Review Process

G. Quality Improvement Program

H. Disease Management Programs, Case Management Program and Clinical Practice Guidelines

I. Behavioral Health Services

J. Other Information

K. Hospital Acquired Conditions and Serious Reportable Events

L. Pharmacy

M. Employee Retirement System of Texas (ERS) Participants Benefit Plan using Blue Essentials Network

Appendix – Terms, Definitions and Rules