Clinical policies and procedures

Use this searchable list to find Blue Shield of California Promise Health Plan clinical policies and procedures which can help you provide your patients with the highest standard of evidence-based medical care that is safe and effective. These policies are updated frequently.

Clinical policies and procedures

10.2.10 Early Start Program and other Linked Services (Medi-Cal)

10.2.100.17 Long-Term Care (Medi-Cal)

10.2.100.19 Case Management Coordination of Care (Medi-Cal)

10.2.100.20 Discharge Planning (Medi-Cal)

10.2.100.22 Experimental and Investigational Services for the Terminally Ill (Medi-Cal)

10.2.100.24 Covered and Non-Covered Services (Medi-Cal)

10.2.100.29 Managed Long Term Supports and Services Care Coordination (Medi-Cal)

10.2.100.3 Non-Contracted Providers (Medi-Cal)

10.2.100.30 Coverage of Transgender Services (Medi-Cal)

10.2.100.31 Medi-Cal PCP Assignment for Medi-Cal and Medicare Full and Partial Duals (Medi-Cal)

10.2.11 Authorization Denial, Pending-Deferral, and or Modification Notification (Medi-Cal)

10.2.14 Organ Transplant (Medi-Cal)

10.2.16 Sensitive Services (Medi-Cal)

10.2.17 California Children’s Services (Medi-Cal)

10.2.2 Direct Observed Therapy for Treatment of Tuberculosis (Medi-Cal)

10.2.20 Sexually Transmitted Infections (Medi-Cal)

10.2.22 Clinical Trials (Medi-Cal)

10.2.23 Returned Member Notification Letter (Medi-Cal)

10.2.24 Member Disenrollment (Medi-Cal)

10.2.29 Case Management Coordination of Care (Medi-Cal)

10.2.3 Family Planning Services (Medi-Cal)

10.2.32 Vision Care Services (Medi-Cal)

10.2.33 Home & Community Based Services (HCBS) Waiver Program (Medi-Cal)

10.2.38 Long-Term Care Services for Former Developmental Care Center Members (Medi-Cal)

10.2.4 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) (Medi-Cal)

10.2.40 Accessing Non-Participating Providers for Continuity of Care (Medi-Cal)

10.2.42 Referral Process for Managed Long Term Services and Supports (MLTSS) (Medi-Cal)

10.2.43 Utilization Management Decision Making Time-Frames (Medi-Cal)

10.2.7 Hospice Care (Medi-Cal)

10.2.8 Dental Services (Medi-Cal)

10.2.9 Child Health and Disability Prevention (CHDP) Program (Medi-Cal)

10.2.92 Community-Based Adult Services (CBAS) (Medi-Cal)

10.2.95 Medical Exemption Requests (MERs) for Continuity of Care (Medi-Cal)

50.2.11 Authorization, Denial, Pending-Deferral, and or Modification Notification (Medicare)

50.2.19 Covered and Non-Covered Services (Medicare)

50.2.20 Expedited Organization Determination (Medicare)

50.2.21 Expedited QIO Review of Coverage Determination (Medicare)

50.2.22 Standard Pre-Service Organization Determinations (Medicare)

50.2.24 Coordination of Medicare and Medi-Cal Services (Medicare)

50.2.27 SNP Model of Care Training for Staff, Provider and IPA-Medical Groups (Medicare)

50.2.30 CMS Timeliness Requirements and Verification of Written UM Organization Determinations via US Mail (Medicare)

50.2.31 Medicare Beneficiary Denial Notices

50.2.32 CMS Part C Reporting (Medicare)

50.2.33 Re-opening and Revising Organization Determinations (Medicare)

50.2.80 CMS Part C and D Reporting - Organization Determinations and Reconsiderations (Medicare)

70.2.1 Emergency Care Services

70.2.10 Retrospective Review

70.2.100 Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT) Services

70.2.12 Reimbursement to Out-of-Plan Providers

70.2.14 Discharge Planning

70.2.16 Out-of-Network Services

70.2.17 Second Opinion

70.2.2 Urgent-Emergent Admission Review

70.2.21 Inter-Rater Reliability (IRR) Audit

70.2.23 Reconsideration

70.2.26 Utilization Management Work Plan

70.2.27A Well Mother and Baby Program: Postpartum

70.2.27B Well Mother and Baby Assessment Home Health

70.2.28 UM to QM Referral Indicators

70.2.29 Evaluation and Review of Experimental and Investigation Therapies and IMR

70.2.29A Investigational Services

70.2.3 Concurrent Hospital Review

70.2.30 Evaluation of New Technologies

70.2.32 Standing Referral - Extended Access to Specialty Care

70.2.32a Standing Referral - Extended Access to Specialty Care for Cancer and other Debilitating Conditions

70.2.33 Reconstructive Surgery

70.2.36 Benefits - Preventive Health Algorithms for Authorizations

70.2.38 Outpatient Encounter Data Processing and Reporting

70.2.39 Sterilization and Information

70.2.4 Elective Admission Review

70.2.40 Care Transitions when Benefits End

70.2.41 Independent Medical Review (IMR) Process

70.2.42 Utilization Management Standards for Medical Decision Making Processes

70.2.46 Minor Consent Services

70.2.47 Member 24-Hour Access to Medically Needed Services

70.2.49 Medical Services Committee Functions

70.2.5 Outpatient and Ambulatory Surgery Review

70.2.50 Prior Authorization Review

70.2.51 UM Report FTP Site Distribution

70.2.6 Assistant Surgeon Review

70.2.61 Minimum Necessary Information Request

70.2.62 Reasonable Safeguards

70.2.63 Confidentiality of Utilization Management/Case Management Information

70.2.64 Under- and Over-Utilization Reporting Mechanisms

70.2.65 Out of Network Member Service Monitoring

70.2.67 Complex Case Management Data Identification

70.2.69 Providers and Members Communication Services

70.2.7 Specialty Care Referral Management

70.2.70 Coordination of Medicare and Medi-Cal Services (SNP)

70.2.71 Record Retention

70.2.72 Nurse Advice Line

70.2.77 Guidelines for Storage of Vaccines for Children

70.2.78 Advanced Directives

70.2.8 Affirmation Statement on Incentives

70.2.83 Definition and Application of Medical Necessity Provision for Treatment Authorization Requests

70.2.84 Therapeutic Enteral Formula

70.2.85 Continuity of Care on Termination of Provider-IPA-Hospital Benefits

70.2.9 Out of Network Self-Referral

70.2.94 CMS Utilization Management Timeliness Standards

70.2.96 Wound Care Management Program

70.2.97 Durable Medical Equipment (DME) Rental and Purchase

90.2.10 Long-term Care (LTC) (CMC)

90.2.11 Coordinating Behavioral Health Care Services for Duals (CMC)

90.2.17 Second Opinion (CMC)

90.2.2 Non-Contracted Providers (CMC)

90.2.25 Continuity of Care (CMC)

90.2.27 Continuity of Care (Nursing Facility) (CMC)

90.2.28 Out-of-Network Services (CMC)

90.2.32 Standing Referral - Extended Access to Specialty Care (CMC)

90.2.4 CMS Timeliness Requirements and Verification of Written UM Organization Determination (CMC)

90.2.47 Members 24-hour Access to Medically Needed Services (CMC)

90.2.50 Prior Authorization Review and Approval Process (CMC)

90.2.6 Care Coordination Data Validation (CMC)

90.2.65 Out-of-Network Member Service Monitoring (CMC)

90.2.8 Post-Acute Discharge and Transitional Care Planning (CMC)

90.2.9 Hospice Care (CMC)

Medical care solutions

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Prior authorization list

View the list of medical services and procedures requiring medical necessity review or supplemental documentation prior to payment.

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Utilization management and clinical practice guidelines

Utilization management (UM) and clinical practice guidelines define healthcare standards applicable to members and providers.

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Pharmacy services and drug formularies

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Population Health Management

Our Disease Management Program provides education, care coordination, and support for members with certain chronic conditions.

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Prior authorization and referral forms

Find common forms which you may need to request prior authorization, as well as patient referral forms.

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Provider Connection

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Blue Shield of California Promise Health Plan has neither reviewed nor endorsed this information.

Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association. Blue Shield of California Promise Health Plan is a Medicare Advantage HMO plan with a Federal Government contract in California. Enrollment in Blue Shield of California Promise Health Plan depends on contract renewal.

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