Name of Manual - Blue Cross and Blue Shield of Minnesota

Blue Plus
Member Benefits Members’ benefits depend upon their type of contract. Benefits for
our standard fully insured contracts may vary from our self-insured
contracts. Because members’ benefits will vary, please use
BLUELINE, provider web self-service, or contact provider service
for specific member benefits.
• Highest level of benefits – Members generally receive the
highest level of benefits when they receive their services from
their PCC or when the PCC authorizes a referral to a specialist.
A list of participating referral providers which is online at
www.providerhub.com is available in the Referral Network
for PCCs directory or at bluecrossmn.com.
• Self-referral – Members may decide to manage their own
health care without involving their PCC. We consider this a
self-referral. In doing so, members usually take on additional
financial responsibilities. A claim may be paid at a lesser
benefit or completely denied, depending on if the member has
a self-referral option.
• Referral bypass – There are some services that will be paid at
the highest level of the member’s benefits without a referral
from the PCC. This is known as a referral bypass or referral
exception. For a listing of referral bypasses, please refer to the
Referral Not Required section of this chapter.
• PCC/Care System - Referral bypass- There may be situations
where a particular PCC or care system has communicated their
wish to have a referral bypass implemented for a particular
situation. This allows the specified service to be paid at the
highest level of benefits without you communicating a referral
to us. If you have questions regarding a PCC specific referral
bypass, please contact provider service. These requests are
handled on an individual basis and must be implemented by
Blue Plus and an authorized person at your clinic.
• Open access – Some contracts have open access for specified
services. The member usually uses a designated participating
network provider and will receive the highest level of benefits
without a referral from the PCC. Some examples include
vision, chiropractic, obstetrics/gynecology (ob/gyn), or
behavioral health care.
6-8 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)