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) Long-Term Care (Medi-Cal) Case Management Coordination of Care (Medi-Cal) Discharge Planning (Medi-Cal) Experimental and Investigational Services for the Terminally Ill (Medi-Cal) Covered and Non-Covered Services (Medi-Cal) Managed Long Term Supports and Services Care Coordination (Medi-Cal) Non-Contracted Providers (Medi-Cal) Coverage of Transgender Services (Medi-Cal) 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)