Blue Shield of California Promise Health Plan and its contracted IPAs and medical groups utilize clinical practice guidelines as standards of health care applicable to members and providers.

The Blue Shield Promise Quality Management Committee performs a review of nationally and locally developed guidelines and gives final approval of the adoption of all guidelines.

All clinical practice guidelines are based on scientific evidence, review of the medical literature, or appropriately established authority, as cited. All recommendations are based on published consensus guidelines that do not favor any specific treatment based solely on cost consideration.

The recommendations for care are suggested as guides for making medical necessity clinical decisions. Clinicians and their patients must work together to develop individual treatment plans tailored to the specific needs and circumstances of each patient.

Providers and members have the right to request a copy of a guideline that Blue Shield Promise has used to make a treatment authorization decision.

The guidelines utilized by Blue Shield Promise come from a variety of sources including:

  • Centers for Medicare & Medicaid Services (CMS)
  • National Coverage Determinations
  • Local Coverage Determinations
  • CMS Benefit Interpretation Manuals
  • Medi-Cal Coverage Guidelines
  • Milliman Care Guidelines®
  • National Guideline Clearinghouse
  • Evidence in the peer-reviewed published medical literature

These guidelines are developed through:

  • Technology assessments and structured evidence reviews
  • Evidence-based consensus statements
  • Expert opinions of healthcare providers
  • Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies
     
Condition Guideline Consensus document
Asthma

NHLBI Guidelines for the Diagnosis and Management of Asthma (Expert Panel Report 3), 2012

Chronic Obstructive Pulmonary Disease (COPD)
Coronary Artery Disease (CAD)
Diabetes
Heart failure

2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America

2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America

Acute Myocardial Infarction with ST-Elevation
2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Acute Myocardial Infarction without ST-Elevation
2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines

Stable Ischemic Heart Disease
2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

Acute Respiratory Tract Infection  
Behavioral and mental health  

Affirmative statement

Blue Shield of California Promise Health Plan affirms that it encourages appropriate utilization of medically necessary member care and discourages under-utilization of services by the following statements:

  • Utilization management (UM) decision making is based only on appropriateness of care and service and existence of coverage.
  • Blue Shield of California Promise Health Plan does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.
  • Financial incentives for UM decision makers do not encourage decisions that result in under-utilization.
  • Providers and practitioners are not prohibited from acting on behalf of the member.
  • Physicians cannot be penalized in any manner for requesting or authorizing appropriate medical care.
  • Practitioners are ensured independence and impartiality in making referral decisions that will not influence:
    • Hiring
    • Compensation
    • Termination
    • Promotion
    • Any other similar matters