Find in-depth information about all of our products and procedures.

The  Capital BlueCross Provider Manual is your reference for information about our Traditional, PPO, POS, HMO, Capital Blue Cross HMO, and Capital Blue Cross PPO products, as well as the administrative requirements and procedures for participating professional, hospital, facility, and ancillary providers. The Provider Manual includes the requirements for Capital Blue Cross  HMO and Capital Blue Cross PPO.

The manual is supplemented by Administrative Bulletins and updated on a periodic basis.

Capital Blue Cross and Keystone Health Plan Central Provider Manual Chapters

Table of Contents

1.0 Introduction

2.0 Contact and Web Site Information

3.0 Provider Responsibilities

4.0 Product Descriptions

5.0 Provider Identification

6.0 Notification from Provider of New/Changed Information

7.0 Provider Automation

8.0 Provider Interactive Voice Response (Provider IVR)

9.0 Eligibility Verification and ID Cards

10.0 General Policies and Standards

11.0 Referrals, Preauthorization and Continuity of Care

12.0 Clinical Management

13.0 Quality Improvement Program

14.0 Laboratory Procedures

15.0 Prescription Drug Program

16.0 Behavioral Health (Mental Health and Substance Abuse) Services

17.0 Payment and Electronic Funds Transfer

18.0 Claims Submission

19.0 Claim Adjustments

20.0 Coordination of Benefits (COB) and Other Party Liability

21.0 BlueCard Program

22.0 Member Information

23.0 Credentialing

24.0 Delegated Arrangements

25.0 Dispute Resolution and Provider Appeals

26.0 BlueJourney HMO and BlueJourney PPO References

Exhibit 1: Member ID Cards

Exhibit 2: Member Rights and Responsibilities

Common resources