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
10.2.1 Direct Observed Therapy Treatment of Tuberculosis (Medi-Cal)
10.2.10 Sensitive Services (Medi-Cal)
10.2.11 California Children's Services (Medi-Cal)
10.2.12 Sexually Transmitted Infections (Medi-Cal)
10.2.13 Clinical Trials (Medi-Cal)
10.2.14 Returned Member Notification Letter (Medi-Cal)
10.2.15 Member Disenrollment (Medi-Cal)
10.2.16 Coordination of Care (Medi-Cal)
10.2.17 Vision Care Services (Medi-Cal)
10.2.18 Home & Community Based Services Waiver Program (Medi-Cal)
10.2.19 Abortion Services (Medi-Cal)
10.2.2 Family Planning Services (Medi-Cal)
10.2.20 Long-Term Care Servucs for Former Developmental Care Center Members (Medi-Cal)
10.2.21 Referral Process for Long-Term Services and Supports (Medi-Cal)
10.2.22 Utilization Management Decision Making Time-Frames (Medi-Cal)
10.2.23 Community Based Adult Day Services (Medi-Cal)
10.2.24 Medical Excemption Requests for Continuity of Care (Medi-Cal)
10.2.25 Long-Term Care (Medi-Cal)
10.2.26 Covered and Non-Covered Services (Medi-Cal)
10.2.27 Managed Long-Term Supports and Services (Medi-Cal)
10.2.28 Coverage of Transgender Services (Medi-Cal)
10.2.29 PCP Assignment for Medi-Cal and Medicare Duals (Medi-Cal)
10.2.3 Early and Periodic Screening, Diagnosis, and Treatment (Medi-Cal)
10.2.30 Concurrent Hospital Review (Medi-Cal)
10.2.31 Out of Network Self-Referral (Medi-Cal)
10.2.32 Retrospective review (Medi-Cal)
10.2.33 Discharge Planning (Medi-Cal)
10.2.34 Well Mother Baby - Postpartum (Medi-Cal)
10.2.35 Well Mother and Baby Assessment Home Health (Medi-Cal)
10.2.36 Standing Referral - Extended Access to Specialty Care (Medi-Cal)
10.2.37 Benefits - Preventive Health Algorithms for Authorizations (Medi-Cal)
10.2.38 Prior Authorization (Medi-Cal)
10.2.39 Under Over Utilization Reporting Mechanisms (Medi-Cal)
10.2.4 Hospice (Medi-Cal)
10.2.40 Continuity of Care for Medi-Cal Members Transitioning into MCP (Medi-Cal)
10.2.41 Out of Network Services (Medi-Cal)
10.2.42 Care Transitions when Benefits End (Medi-Cal)
10.2.43 Emergency Care Services (Medi-Cal)
10.2.44 Second Opinion (Medi-Cal)
10.2.45 Member 24 Hour Access (Medi-Cal)
10.2.46 Providers and Members Communication Services (Medi-Cal)
10.2.47 Evaluation & Review of Experimental & Investigational Therapies & IMR (Medi-Cal)
10.2.48 Investigational Services (Medi-Cal)
10.2.49 Minor Consent Services (Medi-Cal)
10.2.5 Dental Services (Medi-Cal)
10.2.50 Utilization Management to Quality Management Referral Indicators (Medi-Cal)
10.2.51 Private Duty Nursing (Medi-Cal)
10.2.52 Genetically Handicapped Persons Program (Medi-Cal)
10.2.53 Specialty Care Referral Management (Medi-Cal)
10.2.6 Child Health and Disability Prevention Program (Medi-Cal)
10.2.7 Early Start Program and Developmental Disability Services other Linked Services (Medi-Cal)
10.2.8 Auth Denial, Pending/Deferral, and/or Modification Notification (Medi-Cal)
10.2.9 Organ Transplant (Medi-Cal)
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
70.2.21 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
70.2.31 Direct OB-GYN Access Program
70.2.32 Standing Referral - Extended Access to Specialty Care
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 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
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
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 & Application of MCAL Necessity
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 Utilization Management Decision Making
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)
90.2.2 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)
90.2.8 Post-Acute Discharge and Transitional Care Planning (CMC)
90.2.9 Hospice Care (CMC)