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Blue Shield of California Provider Connection Homepage
Guidelines and resources
Find Blue Shield of California and Blue Shield of California Promise Health Plan forms, policies, benefit information, medical guidelines, operating guidelines, manuals, patient care resources and more.
Provider manuals | Guidelines & procedures | Policies & standards | Forms | Drugs & pharmacy | Patient care & BlueCard | Prospective provider resources | Additional resources
Provider manuals

Access our procedure manuals and benefit guidelines.

HMO Benefit Guidelines
Find benefit details for Blue Shield IPAs, medical groups and their contracted providers.
HMO IPA/Medical Group Procedures Manual
Find policies and procedures for Blue Shield IPAs, medical groups and their contracted providers.
Hospital and Facility Guidelines
Find policies and procedures for Blue Shield network hospitals and other facilities.
Independent Physician and Provider Manual
Find policies and procedures for direct-contract Blue Shield network providers.
Medical Interface Manual
Learn about Blue Shield's Mental Health Service Administrator protocols for coordination of medical and behavioral health care.
Blue Shield Promise Medi-Cal Provider Manual
Find policies and procedures for Blue Shield Promise Medi-Cal providers.
Blue Shield Promise Nursing Facility reference guide
Get information about policies and requirements for Nursing facility providers
Primary Care Pay-for-Value Hybrid Payment Model Manual
For primary care practices to alleviate the financial impact of COVID-19 and connect reimbursement to patients. (PDF, 14 MB)
Guidelines and procedures

Find operating guidelines for clinical practices, hospitals, preventive health guidelines and procedures for continuing network participation.

Clinical practice guidelines
Find recommendations for evaluating common acute and chronic conditions.
Procedures for providers continuing participation in Blue Shield network
Find procedures and forms.
Preventive health guidelines
Access preventive health guidelines for healthy children, adolescents and adults.
Utilization management decision procedures
Learn how Blue Shield makes utilization management decisions.
National Provider Identifier (NPI)
Learn about the NPI - the unique number assigned to all healthcare providers.
Claims guidelines
Learn about claims submission guidelines and time frames, rules for payment, and more.
Fraud prevention guidelines for Blue Shield Promise providers
Learn how to report suspected healthcare fraud and find prevention tips and guidelines.
Health assessment guidelines for Blue Shield Promise Medi-Cal providers
Learn how to conduct an assessment, find patient questionnaires, forms and training materials.
Policies and standards

Find information about standards for HIPAA transactions, medical records, medication and member data policies, as well as provider dispute regulations.

Other payer summary list

Claim payment policies and rules

Medication policies
Find policies and announcements about medication, treatments, and other related topics.
Medical policies & procedures
Learn about our medical policies, policy goals and new technologies coverage decisions process.
HIPAA transaction standards
Read an explanation of HIPAA and patient medical records protection standards.
Medical record standards
Read Blue Shield's policy on medical record standards and documentation requirements.
Member PHI confidentiality and protection policy
Find Blue Shield's policy for sharing and disclosing confidential member data.
Claims and dispute resolution regulations
Review the DMHC regulations summary and a compliance overview.
Access to care standards
Learn about guidelines Blue Shield uses to ensure our members have proper access to care (PDF, 288 KB)
Forms

Download and print commonly requested prior authorization forms procedures, injectable drugs (office administered and home self-administered), and oral/topical drugs, as well as forms you may need to submit your claims or enroll into EDI.

Special guidelines for claim forms

Authorization forms
Find prior authorization forms for procedures and oral, topical and injectable drugs.

Delegation oversight forms
Find delegation oversight monthly and quarterly reports.

HICE data reports
Use this data to satisfy requirements established by the Health Industry Collaboration Effort (HICE).

Network and procedure forms
Download Blue Shield forms that can help meet credentialing requirements.

Patient care forms
Find commonly requested forms designed to help you serve Blue Shield members and patients.

Forms for Blue Shield Promise providers
Find referral, authorization, service request and claim forms.
Drugs and pharmacy

Search our drug formulary database, find prior authorization forms and procedures for different types of prescriptions, learn about our mail service pharmacy for medication delivery and find out about generic alternatives.

Outpatient drug formulary
Access online drug formularies, download printable formularies and prior authorization forms.
Prior authorization procedures
Find an explanation of procedures for drugs requiring prior authorization and required forms.
Mail service pharmacy
Get information about a prescription home delivery service - CVS Caremark Mail Service.
Generic drug policy
Read generic drugs prescription policy and criteria they must meet to be included in formulary.
Medical specialty drug resources
Access resources specific to medications covered under member medical benefits.
Patient care resources and programs

Find information to help assist your patients, including educational materials, language assistance resources and resources for the disabled, preventive health guidelines and more. Get images of ID cards by plan type, and information about member rights and responsibilities.

Also, find information about BlueCard program and tools, which will help you serve your patients who are out-of-state Blue plan members, and submit claims for your services.

Patient care resources
Find information that can help you assist your patients.
Provider and member programs
Learn about the programs supporting our healthcare providers in offering our members access to high-quality care.
BlueCard Program
Find information and tools you need to serve patients covered by other Blue plans.
Enhanced Care Management (ECM)
Learn more about enhanced care management for eligible Medi-Cal beneficiaries
Dual Special Needs Plan Model of Care program
Learn about the program and its requirements for Blue Shield and for providers who care for D-SNP enrollees.
Community Supports
Community Supports are optional services (non-benefits) that Blue Shield Promise may offer to eligible Medi-Cal members.
Prospective provider resources

We welcome physicians and other healthcare professionals. Learn about the steps to join our network and locate required applications and forms.

Instructions for providers continuing participation in our network

Credentialing requirements
Get a checklist of requirements to become a Blue Shield Network Provider.
Join the Behavioral Health provider network
Get applications, forms, and credentialing documents.
Join the Blue Shield of California provider network
Get instructions, applications, forms, and credentialing documents.
Join the Blue Shield Promise provider network
Learn how to become a Blue Shield Promise Medi-Cal provider.
Become a California Children's Services paneled provider
Find out how you can help us ensure that children have access to care they need.
Additional resources

Instructions for how to access and use most website tools plus direct links to resources on the website.

Provider Connection Reference guide for all providers (PDF, 4.4 MB)

Provider Connection training

Provider referrals for Blue Shield Promise members
Verify provider participation in Blue Shield Promise Medicare, Medi-Cal or Cal MediConnect network.
Provider referrals for Blue Shield members
Verify provider participation in Blue Shield of California member's plan network with Find a Doctor tool.
Sign up for webinars
Learn about our tools and how to use them in our upcoming webinars.
Manifest MedEx
Learn about the statewide, next-generation health information exchange (HIE).
Guidelines & resources contacts
See phone numbers, addresses, and more.
California Clinical Data Project
Download latest monthly CALINX file

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