The “Prior authorization list” is a list of designated medical and surgical services and select prescription Drugs that require prior authorization under the medical benefit. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to payment authorization.
Members and providers are encouraged to obtain prior authorization and may call Customer Service to inquire about the need for prior authorization. While the list below covers the medical services, drugs, and procedures that require authorization prior to rendering; Blue Shield may require additional information after the service is provided.
If further information is required to process the payment Blue Shield’s Claims department will reach out and will request the specific information at that time. Before providing service please contact Customer Service or access the provider connection website to verify the service is a covered benefit.
Blue Shield of California providers
Prior authorization for the services listed below is highly recommended. For more information on obtaining prior authorization review refer to your provider manual. If authorization was not obtained prior to the service being rendered, the service will likely be reviewed for medical necessity at the point of claim.
Please include medical records when you are ready to submit for claim payment, review our medical policies, and verify the service is a covered benefit online through our provider connection website or contact Customer Service. If prior authorization was obtained and you are submitting an offline (i.e. paper) claim, remember to attach a copy of the prior authorization letter.
Prior authorization requirements for out-of-area Blue Plan members
Providers can view medical policy and general prior authorization requirements for patients who are covered by an out-of-area Blue Plan, using our Medical policy and general prior authorization requirements for out-of-area members tool.
Blue Shield of California Promise Health Plan providers
See the list of the designated medical and surgical services and select prescription drugs, which require prior authorization under a Blue Shield of California Promise Health Plan medical benefit.
Advanced imaging services
Prior authorization medical necessity reviews are highly recommended for certain non-emergency outpatient advanced imaging procedures (CT, MRI, MRA, PET, cardiac nuclear medicine) for Administrative Services Only (ASO), HMO Direct Contracting and PPO plans. Review requests for services are performed by National Imaging Associates. Visit the NIA website to use this service, or call (888) NIA-BLUE (642-2583).
Spine surgery and pain management services
Prior authorization medical necessity reviews are highly recommended for certain spinal procedures (spinal surgery, spinal injections, spinal implants) for Administrative Services Only (ASO), HMO Direct Contracting, and PPO plans. Review requests for services are performed by National Imaging Associates. Visit the NIA website to use this service, or call (888) NIA-BLUE (642-2583).
Federal Employee Program
Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements. For both outpatient procedures and treatment requiring an inpatient stay, call (800) 633-4581 to obtain prior authorization.
If you are an Out-of-area provider treating a Blue Shield of California member, contact the customer service phone number on the back of the member’s card to verify if the service is a covered benefit under the plan and to verify if prior authorization is required.
Prior authorization list (Medical)
The document below lists prior authorization codes for Blue Shield (including Medicare 65+).
View Blue Shield Prior Authorization list (PDF, 107 KB)
Prior authorization information for medications
Prior Authorization information for medications can be found here for the following plans: Medicare Plans [Part D drug list, Part B PPO], Medical Benefit Commercial Plan, Medical Benefit PHP Medi-Cal Plan, and Pharmacy Benefit Commercial Plan