Blue Shield has an established utilization management (UM) program to help ensure that our members receive quality health care. The UM program looks at the healthcare services provided to our members and evaluates whether they are medically necessary, timely, and in keeping with both Blue Shield established guidelines and community standards. This program is structured around the belief that medical decisions should be made by qualified individuals using nationally recognized clinical criteria.
Our UM decisions are made by qualified medical staff and are based only on appropriateness of care and service, and existence of coverage (i.e., medical necessity within contracted benefits). Blue Shield does not specifically reward practitioners or other individuals (e.g., medical groups or doctors’ employees) for issuing denials of coverage or service area There are no financial incentives for UM decision makers and therefore, Blue Shield does not encourage decisions that result in underutilization.
Blue Shield uses evidence-based criteria and Blue Shield medical policies as guidelines for decisions about coverage of care. These criteria and guidelines are adopted with input from network physicians and are regularly reviewed for clinical appropriateness. Our use of guidelines is not based on financial objectives or volume targets.
To request Utilization Management criteria or with questions, contact UM staff by phone or fax:
Phone:(800) 541-6652 (option #6)
Fax: (844) 807-8996
Blue Shield's policy for UM decisions can also be found in the HMO IPA/Medical Group Procedures Manual.
The information about utilization management for Blue Shield of California Promise Health Plan providers can be found on Utilization management and clinical practice guidelines page.