Blue Shield and Blue Shield Promise members may require prior authorization for some procedures or services. Review the prior authorization criteria below and learn how to submit requests.
Authorizations for Blue Shield PPO members
Submit most medical, medical benefit drug, and behavioral health authorization requests through AuthAccel, with the exception of certain services specified below under the authorizations that must be submitted through Evolent. You can also access training and support tools for using AuthAccel.
How to submit authorization requests
Medical, medical benefit drug, and behavioral health requests
Medical inpatient urgent requests
Outpatient pharmacy and retail pharmacy requests for Blue Shield commercial PPO and Medicare PPO members
Retail pharmacy authorizations for Blue Shield Federal Employee Program (FEP) PPO plan members
Authorizations for Blue Shield HMO members
Check with the member’s assigned IPA for next steps.
If you’re referred back to Blue Shield or you are a contracted network provider, use Blue Shield’s AuthAccel tool or contact us for most requests, with the exception of certain services specified below under the authorizations that must be submitted through Evolent
Authorizations that must be submitted through Evolent
Commercial HMO members
Prior authorization requests for radiation oncology, medical benefit oncology drugs, advanced imaging, spine surgery, and pain management services must be submitted to Evolent for HMO members with a Blue Shield directly contracted primary care physician and Trio HMO members with a virtual primary care physician.
Medicare PPO members
Authorization submission to Evolent for the types of care listed below also apply to our Medicare PPO members
Authorizations to submit through Evolent:
- Radiation oncology: Submit prior authorization requests for radiation oncology administered in the outpatient and office setting using the Evolent provider portal.
- Medical benefit oncology drugs: Submit prior authorization requests for medical benefit oncology drugs administered in the outpatient and office setting using the Evolent provider portal.
Submit CAR-T drug requests administered in the inpatient, outpatient, and office setting using the Evolent provider portal.
- Submit prior authorization requests for advanced imaging, spine surgery, and pain management using the Evolent provider portal.
Authorizations for Blue Shield Promise (Medi-Cal) members
Medical and Medical Benefit Drugs
Check with the member’s assigned IPA for next steps.
If you’re referred back to Blue Shield or you are a contracted network provider, use Blue Shield’s AuthAccel tool or contact us.
Outpatient/retail pharmacy
Since January 1, 2022, the state-run program Medi-Cal Rx began managing Medi-Cal pharmacy benefits. The Department of Health Care Services (DHCS) administers the Medi-Cal Rx program through their vendor, Magellan Rx. To learn more, visit the Medi-Cal Rx website any time or call (800) 977-2273, available 8 a.m. to 5 p.m. Pacific Time, Monday through Friday.
Blue Shield commercial, Medicare, and FEP PPO members
Blue Shield Promise members
IPA authorization log
Submit logs of approvals, denials, and partial denials for a medical or pharmacy service through the IPA authorization log upload.
Out-of-area Blue Plan members
Go to pre-service review to find online tools to verify medical policy, determine pre-service requirements, and request authorization.
Visit BlueCard Program to find information and tools you need to assist patients covered by other Blue Plans.
AuthAccel online authorizations system
Learn how to request authorizations, view status, and see the latest system updates.
Drug formulary
Search our drug formulary database and find drug policy information on oral, topical and home-injectable drugs.
Medical policies and procedures
Learn about our medical policies, policy goals, and new technologies coverage decisions process.
Medication
Read our medication policies for commercial and Medicare members
Utilization management
Read about our approach to utilization management decision-making for medical and behavioral health care.
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All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.
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