000 Form

Blue Cross Blue Shield of Massachusetts Managed Care, PPO and Indemnity Guidelines Commercial Members: Managed Care (HMO/POS) Guidelines All authorization requirements are determined by the individual’s subscriber certificate, explanation of coverage, or summary plan description. In general:  Any specialist visit requires a referral o No referral is required for a visit to an OB/GYN specialists.  Pre-authorization is required for an inpatient admission. Commercial Members: PPO and Indemnity Guidelines All authorization requirements are determined by the individual’s subscriber certificate, explanation of coverage, or summary plan description. In general:  No referral is required for a specialist visit.  Pre-authorization is required for an inpatient admission.  Pre-authorizations are not required for most outpatient services, except as those defines in the subscriber certificate. Medicare Members: Managed Care HMO Blue Guidelines Services must meet all of the following criteria:  be medically necessary  meet the criteria for coverage described in BCBSMA medical policy,  prescribed by a plan physician and  provided by a network provider. Referrals are required for all visits to a specialist. Pre-authorization is required for an inpatient admission. Medicare Members: PPO Guidelines Services must meet all of the following criteria:  be medically necessary  meet the criteria for coverage described in BCBSMA medical policy,  prescribed by a plan physician and  provided by a network provider. Referrals are not required for visits to a specialist. Pre-authorization is required for an inpatient admission.