Blue Cross Blue Shield Axis® Provider Insights (Provider Insights1) is a national dataset that enables plans to report on measures of quality, appropriateness, and cost/efficiency nationally at the individual NPI level.
This dataset is a compilation of claims and quality data developed by the Blue Cross Blue Shield Association, Blue Health Intelligence 2, and Motive Medical Intelligence.3
- Draws from Motive Medical Intelligence for quality and appropriateness insights and from Blue Health Intelligence for cost/efficiency.
- Evaluates performance for individual physicians across the following 20 specialties, including primary care, which represents approximately 60% of total medical spend.
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Using this dataset, along with Blue Cross Blue Shield of Massachusetts data, we are placing PCPs and specialists into three performance categories.
- Category 1 providers: Scored best on a combination of quality, appropriateness, and cost/efficiency of care.
- Category 2 providers: Scored in the middle range of performance.
- Category 3 providers: Scored lower on cost/efficiency of care or scored lower on quality of care and appropriateness of care.
Blue Cross Blue Shield of Massachusetts will use these categories in the development of new and evolving products and solutions.
Providers in the 20 specialties listed above can log in to view our Performance Category Methodology.
A: Providers are placed into one of three categories based on their overall performance compared to other providers nationally in the same specialty.
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Scored best on a combination of quality of care, appropriateness of care, and cost/efficiency of care. |
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Scored in the middle range of performance. |
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Scored lower on cost/efficiency of care or scored lower on quality of care and appropriateness of care. |
Providers in one of the 20 specialties listed above can log in and refer to the Performance Category Methodology document for definitions of appropriateness of care, quality of care, and cost/efficiency of care.
A: The dataset will be refreshed annually and we will make updates to the categories as appropriate. We anticipate that the categories will be updated the following January 1.
A: Not at this time. In the future, we expect to list providers in provider directories.
1. Blue Cross Blue Shield Axis (BCBS Axis) Provider Insights was developed by the Blue Cross Blue Shield Association, Blue Health Intelligence, and Motive Medical Intelligence.
2. Blue Health Intelligence® (BHI®) is a company that provides analytic intelligence information tailored to the Blue system that helps Blue Plans improve health care access, equity, and affordability. Privately owned by the Blue Cross Blue Shield Association (BCBSA) and 17 of the nation’s Blue Plans, BHI is focused on using the Blue systems’ collective data assets to provide measurable impact to Plans nationwide. Visit bluehealthintelligence.com to learn more.
3. Motive Medical Intelligence is a company that provides analytics solutions to help health plans with insights on cost/efficiency and quality of care. Visit motivepw.com to learn more.
Blue Benefit Administrators of Massachusetts is a wholly-owned subsidiary of Blue Cross Blue Shield of Massachusetts. We use Blue Benefit Administrators as a third-party administrator of medical and dental plans that we sell to self-funded employer groups. The employers who purchase these plans may customize member benefits to its group’s needs.
These plans offer in- and out-of-network benefits to give members the flexibility to coordinate their care. Members have access to the Blue Cross Blue Shield of Massachusetts network of providers and the National BlueCard® Network for in-network care.
Blue Benefit Administrators members have a unique ID card with a non-Social Security-based number and other features specific to these plans.
How to verify member eligibility
- Call Customer Service at the number on the back of the member’s ID card.
- Go to www.bluebenefitma.com and select "Providers".
Outpatient procedure notification
Some employers require pre-certification for designated outpatient procedures. Once you have validated that a procedure requires certification, you may fax this form to our Utilization Review Department to start the process.
Filing claims
You can submit electronic claims using a clearinghouse.
- Use payor ID 03036 to submit claims electronically.
- Call your clearinghouse for help submitting claims.
Paper claims and correspondence:
Blue Benefit Administrators of Massachusetts
PO Box 55917
Boston MA 02205-5917
Contact Blue Benefit Administrators directly for all eligibility, benefit, claim, reimbursement, or authorization inquiries.
- www.bluebenefitma.com
- 1-877-707-2583
We provide benefits to more than 100,000 federal and postal employees and their families in Massachusetts through the Federal Employee Program (FEP) and the Postal Service Health Benefits Program. Members have the choice of three preferred provider organization (PPO) medical plans—FEP Blue Standard™, FEP Blue Basic™, and FEP Blue Focus®—and a dental supplement plan. You can see a side-by-side comparison of benefits at fepblue.org.
Features of the FEP Blue Standard Option (PPO):
- Choice of providers inside or outside the preferred provider network
- No referrals required
- No copayment for covered adult preventive screenings and routine physical exams, and well-child care to age 22
- A mail service program that helps members to save on prescription costs
- A preventive (limited) dental benefit
Features of the FEP Blue Basic (PPO):
- Choice of providers from our nationwide preferred provider network
- No referrals required
- No copayment for adult preventive care and well-child care to age 22
- No deductible
- A preventive (limited) dental benefit
Features of FEP Blue Focus:
- Choice of providers from our nationwide preferred provider network
- Our most affordable FEP plan
- Has copayments, co-insurance, and a deductible
- Includes a reward program for annual physicals
- Physician care is $10 for each for the member’s first 10 combined professional visits
- Does not include coverage for dental care, non-preferred drugs, skilled nursing facility care, hearing aids, or long-term care
Features of the Medicare Prescription Drug Program:
- Used by FEP members with part A and/or part B Medicare
- Broad range of covered medications with lower out-of-pocket costs for medications.
- Four tiers of coverage for generics, preferred brand name, non-preferred brand name, and specialty medications
- Network of more than 65,000 retail pharmacies (administered by CVS Caremark); mail service pharmacy (for Blue Basic and Blue Standard only).
Review the formulary or learn more at fepblue.org.
We offer several different types of HMO Plans:
We offer the following types of HMO plans:
- Blue Select Plans
Members select a primary care provider (PCP) in the HMO Blue Select Network (a limited, Massachusetts-based network). - HMO Blue Plans
Members select a PCP in the HMO network. The PCP coordinates the member's care and refers the member to a network specialist, if necessary. - HMO Blue New England Plans
Members of our HMO Blue New England health plans must choose a PCP from any of the provider networks in the six New England states (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). - HMO Deductible Plans
Members must select a PCP in the HMO network. They also pay a deductible before they receive benefits under these plans. - Access Blue
These plans give members the option to go directly to a specialist or any doctor in the network without a referral. Authorizations maybe required for some services. Members must choose a PCP from any of the provider networks in the six New England states (Connecticut, New Hampshire, Maine, Rhode Island, and Vermont).
Our Blue Choice (POS) plans offer managed care networks while giving members the freedom to seek care from either an in-network provider, or from an out-of-network provider with higher out-of-pocket costs. Through Blue Choice plans, members have:
- A primary care provider (PCP) to coordinate all PCP/Plan Approved Benefits care
- The flexibility to self-refer to any Blue Cross participating provider (at a higher cost). Please note that Blue Choice 2 plans allow members to self-refer to any licensed, covered provider.
Please note these plans may require the member to pay a cost share (deductible, copayment, or co-insurance) for covered services.
We recommend providers check member eligibility and benefits before rendering services.
Indemnity plans are referred to as traditional fee-for-service plan designs, where the indemnity provider is paid a pre-determined fee for each service provided.
Indemnity plans offer full coverage for most services after the member pays a copayment or a deductible. Some Indemnity plans require the member to pay a percentage of the charges for certain services, called co-insurance. There may also be a limit on the amount of co-insurance a member or family must pay in a given year.
Members may choose from any participating indemnity provider (there is no primary care provider who coordinates care) and no referrals are required. Prior authorization may be required for certain services, so be sure to check member benefits and eligibility.
Some of our HMO, PPO, and EPO members have a plan with a limited network of providers—a network that’s smaller than our traditional HMO and PPO networks.
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We also work with other Blue Plans to offer a national limited network: the Blue High Performance NetworkSM (Blue HPN SM). |
Members with an HMO Blue Select plan have a smaller network of doctors and hospitals to choose from than our traditional HMO network.
- Functions like a traditional HMO, but with a concentrated network of lower-cost doctors and hospitals.
- Members must choose a primary care provider (PCP) from their limited network of providers.
- HMO members only have coverage from in-network providers, except in specific circumstances (for example, urgent or emergent care).
- Prescription plan coverage may be with us. If it is, you’ll see an Rx symbol on the front of the member’s ID card.
- Referral and authorization rules are the same as our non-limited network HMO plans.
How to identify a member with a limited network using their Member ID card
- On the front of the card, we’ll indicate if they have a “limited” network of providers (see sample ID card below).
Tip: Members who have our MyBlue member app can email you a copy of their ID card.
- In the EB05 segment, you’ll see “HMO BLUE SELECT”
- In the MSG segment, look for “HMO BLUE LIMITED NETWORK”
For in-network care, please refer to another Blue Select limited network provider.
- You can find a network provider using our Find a Doctor & Estimate Costs tool at bluecrossma.com/findadoctor.
- In the drop-down of network choices, choose HMO Blue Select
| If your participation status for our limited network is | And the member has an HMO plan with the HMO Blue Select limited network |
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| In-network provider |
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| Out-of-network provider |
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| Non-participating provider |
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- Members are encouraged to seek care from an in-network provider whenever possible.
- Referrals are not required.
- Emergency care is covered.
- Select Blue is available to self-insured employers who can choose PPO and EPO benefit plans with the Select Blue network.
- Blue Benefits Administrators (BBA) administers the benefits.
Sample ID card for Select Blue members.
For eligibility and benefits, claim, reimbursement, or authorization inquiries, contact BBA:
- Online at bluebenefitma.com
- By phone at 1-877-707-2583
| Electronic | |
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| Through a clearinghouse, use electronic payer ID 03036 | Blue Benefit Administrators of MA P.O. Box 55917 Boston, MA 02215-3326 |
| For services | Select Blue Exclusive Provider Organization (EPO) Plans | Select Blue PPO Plans |
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| Performed by a participating Select Blue in-network provider |
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| Performed by a participating Select Blue out-of-network provider |
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| Performed by a non- participating provider |
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- Providers and members can use Blue Benefits Administrators' Locate a Network Provider tool to find a doctor or other health care provider.
- Our Blue Benefits Administrators Handbook
- ConnectCenter
- Providers and members can use Blue Benefits Administrators' Locate a Network Provider tool to find a doctor or other health care provider.
- Our Blue Benefits Administrators Handbook. Log in and go to Office Resources>Policies & Guidelines>Provider Manuals.
- ConnectCenter
- Launched in 2021, this national high-performance network is available in more than 65 major U.S. markets, including all top 10 U.S. cities.
- In Massachusetts, the Blue HPN service areas are Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester counties.
- In-network care only
- Members do not have access to out-of-network providers, except for emergent care in the Blue HPN geographic area or urgent and emergent care outside of a Blue HPN geographic area.
Members do not have coverage for out-of-network care. For in-network care, please refer to another Blue HPN provider.
- You can find a network provider using our Find a Doctor & Estimate Costs tool at member.bluecrossma.com/fad.
- In the drop-down of network choices, choose Blue High Performance
| For services | Advantage Blue EPO plans |
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| Performed by a participating Blue HPN in-network provider | Reimbursement is paid at PPO contracted rates. |
| Performed by a participating Blue HPN out-of-network provider | Reimbursement for urgent or emergent services only will be paid at PPO contracted rates. Members may not be balance billed. |
| Performed by a non-participating provider | Except for emergency services, there are no benefits for members who choose to receive services outside of the Blue HPN provider network. Reimbursement for emergency services will be paid directly to the subscriber, who will be responsible for reimbursing the provider. |
Plans with limited networks
| Plan | Network | Administered by |
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HMO
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HMO Blue Select | Blue Cross Blue Shield of Massachusetts |
PPO
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Select Blue | Blue Benefit Administrators of Massachusetts, our third party administrator |
EPO
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Blue High Performance Network | Blue Cross Blue Shield of Massachusetts |
To see plan information on our Medicare site, please enter a Massachusetts zip code.
| Plans | Plan options | Plan type description |
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| Dental Plans |
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Medex and Medicare Advantage direct-pay members have the option to purchase one of these plans. Our Medicare Advantage plans include coverage for limited dental services. Claims will need to be coordinated between the Medicare Advantage plans and the Dental Blue 65 plan. |
| Direct-pay Medicare Supplement Plans |
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One of these Medicare supplement plans (Medigap) can be added to Medicare Parts A and B coverage to fill the "gaps" in a member’s Medicare coverage. |
| Group Medicare Supplement Plan |
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Only offered through employers or unions. Can be added to Medicare Parts A and B to fill "gaps" in a member’s Medicare coverage. Has a traditional prescription benefit or can be paired with the Blue MedicareRx (PDP) plan. |
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Managed care plan only offered through employers. Can be added to Medicare Parts A and B to fill "gaps" in a member’s Medicare coverage. Requires selection of a primary care provider. Referrals to specialists are required for certain services. Has a traditional prescription benefit or can be paired with the Blue MedicareRx (PDP) plan. | |
| Medicare Advantage Plans |
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We offer seven direct-pay and three group Medicare Advantage plans. These plans provide coverage for all Original Medicare benefits and additional benefits beyond Original Medicare, like routine vision and hearing, plus prescription coverage. Note: Members can find a doctor in their network by selecting the appropriate network— "Medicare HMO Blue" or "Medicare PPO Blue"— in Find a Doctor & Estimate Costs. |
| Prescription Drug Plans | Direct-pay; group plans are also available
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A stand-alone prescription drug plan (PDP) available to Medicare beneficiaries living in Central New England: Connecticut, Massachusetts, Rhode Island and Vermont. |
View detailed product information at our Medicare Options site, medicare.bluecrossma.com.
National Medicare Coverage Decisions
Learn more about national coverage determination for Medicare.
PPO (Preferred Provider Organization) plan
PPO plans offer two levels of benefit: Members can select from health care providers who are part of the nationwide Blue Cross Blue Shield PPO Network (preferred), as well as from providers who are out of our network. Members do not need to select a primary care provider or get referrals from a primary care provider to see a specialist.
In-Network
- Health care providers contract with our nationwide network of preferred providers.
- Members generally have a lower cost-share (copayment, deductible, or co-insurance) when they use these preferred providers.
Out-of-Network
- Health care providers are not contracted with the nationwide preferred provider network.
- Members generally have a higher cost-share (copayment, deductible, or co-insurance) and may be billed for the difference between your charge and the allowed amount (balance billing).
- If the member has a Select Blue limited network PPO plan, please refer to the reimbursement information on our limited network page.
- Health care providers are not contracted with the nationwide preferred provider network.
- Members generally have a higher cost-share (copayment, deductible, or co-insurance) and may be billed for the difference between your charge and the allowed amount (balance billing).
- If the member has a Select Blue limited network PPO plan, please refer to the reimbursement information on our limited network page.
EPO (Exclusive Provider Organization) plan
With EPO plans, such as our Advantage Blue plan, members must use health care providers who are part of the Blue Cross Blue Shield PPO Network to receive benefits. With the exception of emergency services, there are no benefits for members who choose to receive services outside of the preferred provider network. Members do not need to select a primary care provider or get referrals from a primary care provider to see a specialist.
We recommend providers check member eligibility and benefits before rendering services.
To meet market demands for products that offer cost-saving incentives to members for selecting high-quality, lower-cost providers, we offer Blue Options tiered network products. Primary care providers and hospitals are grouped into tiers based on cost and nationally accepted measures for quality. The out-of-pocket cost the member pays for care is based on the benefits tier of their primary care provider or acute care hospital. This encourages members to consider the cost and quality each time they get care.
| Benefits tier | Who is included | Member cost |
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| Enhanced |
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$ — lowest cost |
| Standard1 |
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$$ — moderate cost |
| Basic |
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$$$ — highest cost |
1. In limited circumstances, to increase local access, the Standard Benefits Tier includes certain providers whose scores would put them in the Basic Benefits Tier.
Note: We do not tier specialists or other clinicians and facilities. Primary care providers were measured based on their HMO patients as part of their provider group, and hospitals were measured based on their individual facility performance. Provider groups can be composed of an individual provider, or a number of providers who practice together. Tier placement is based on cost and quality benchmarks where measurable data is available. Providers without sufficient data for either cost or quality are placed in the Standard Benefits Tier. Primary care providers that do not meet benchmarks for one or both of the domains and hospitals that do not meet benchmarks for cost or that use nonstandard reimbursement are placed in the Basic Benefits Tier.
This web site gives general information about our tiered network plan designs. There are currently three tiered Options plan designs called HMO Blue Options, HMO Blue New England Options, and Preferred Blue PPO Options. In our tiered plans, members pay different levels of cost share (copayments, coinsurance, and/or deductibles) depending on the benefits tier of the provider furnishing the services. A provider's benefits tier may change. Overall changes to the benefits tiers of providers will happen no more than once each calendar year. As each member renews, their benefit will be updated to reflect the change in tiers. For help in finding the benefits tier of a provider, visit Find a Doctor & Estimate Costs and search for the appropriate network.
Use our Find a Doctor & Estimate Costs tool to see the tier of a doctor or acute care hospital. Or, download a copy of our hospital tiering lists to see how individual hospitals are tiered based on the member’s plan design.
Blue Options v5 Hospital Tiering List HMO Blue New England Options v5 New Hampshire Hospital List
We recommend providers check member eligibility and benefits before rendering services.
