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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

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Network Physician Rights and Responsibilities (PPO)



As a network Physician, you have the right to:  
Request that a patient be reassigned if an acceptable physician-patient relationship cannot be established
Receive timely payment for covered services according to their contract
Be treated courteously and with respect by BCBSGa members and personnel
Obtain all necessary information to treat their patients
Express their opinions, concerns, or complaints in a constructive and respectful manner to BCBSGa
File an appeal and be given due process
Collect any co-payment or co-insurance for covered services
Collect for non-covered services, with proper disclosure
Discuss, based on their opinions, all medically necessary or appropriate care with patients

As a network Physician, you have the responsibility to:  
Cooperate with all BCBSGa administrative, quality, and utilization management guidelines and programs
Ensure that the confidentiality of medical information is protected
Treat patients and BCBSGa personnel with courtesy and respect
Seek only authorized co-payments and specifically authorized payments for non-covered services from BCBSGa member patients
Strive to improve the health of all patients by offering and providing all necessary preventive services appropriate to their specialty
Discuss a patient’s health care status and treatment options with that patient or his or her legal guardian, regardless of whether the information concerns a covered treatment or benefit
When a patient requests it, disclose a general description of the way their BCBSGa reimbursement contract works
Respond to member requests for specific information about their practice, including practice statistics (i.e. the numbers of a specific procedure performed), their credentials (i.e. where they went to medical school, board certification), and patient satisfaction measures

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