Here’s what you need to know about the Hospital Blue^SM product and referral process

Some self-funded Michigan hospitals have a specific type of PPO coverage for their employees called Hospital Blue. Hospital Blue allows an employer to create a provider network for his or her employees.

The product consists of three cost-share tiers — domestic, in network (PPO) and out of network (non-PPO). The domestic tier is made up of select providers designated by the hospital employer to process at the tier 1 benefit level. These providers are generally employed by or through the hospital. All PPO participating providers fall into the tier 2 category and non-PPO providers are tier 3.

Under certain circumstances, some of these employers allow their members to go outside of their domestic network for services without a financial penalty. For example, during a medical emergency or if a member needs specialized treatment unavailable within their domestic network. These situations require a Hospital Blue referral form signed by the member’s domestic provider. Currently, a few of the Hospital Blue policies offer this referral benefit.

To get the Hospital Blue referral benefit from a tier 2 or 3 provider, an eligible member would obtain the Hospital Blue referral form and take it to his or her domestic, or tier 1, provider. If the domestic provider agrees to the referral, the Hospital Blue referral form should be completed and signed by the domestic provider. The member then presents the form to the non-domestic provider.

The non-domestic provider should include the domestic provider’s information as the referring physician on any claims submitted for the Hospital Blue member. For paper claims, the information should be submitted in field 17 of a 1500 Health Insurance Claim Form. For electronic claims, the information should be submitted in loop 2310A. This allows claims to process at the correct benefit level when they are initially submitted while reducing the need for reprocessing.