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Blue Shield of California Promise health plan logo
  • Home
  • Our plans
    • Overview
    • Cal MediConnect plans
    • Medi-Cal
  • Cal MediConnect members
    • Overview
    • Get to know your plan
    • Plan documents
    • Benefits information
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    • Find a provider
    • Health and wellness
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    • Clinical policies, procedures and guidelines
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Please select your plan year to access Cal MediConnect plan information

2021   2022
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  • Provider forms

Provider forms

Download and print commonly requested forms for prior authorizations, coverage determination requests, referrals, screenings, enrollment for electronic claims submission and remittance advices, and more.
  • Authorization request forms
    • Behavioral Health Treatment Authorization Request Packet (PDF, 358 KB)
    • Community Based Adult Services (CBAS) Inquiry (PDF, 242 KB)
    • Community Based Adult Services (CBAS) Treatment Authorization Request (PDF, 782 KB)
    • DME Treatment Authorization Request (PDF, 171 KB)
    • Home Health Treatment Authorization Request (PDF, 187 KB)
    • Long Term Care Custodial Authorization Request - Room & Board (PDF, 326 KB)
    • Long Term Care Authorization Request (PDF, 2.9 MB)
    • Non-Emergency Medical Transportation (NEMT) Physicians Certification Statement (PDF, 115 KB)
    • Outpatient Treatment Authorization Request (PDF, 156 KB)
    • Prescription Drug Prior Authorization and Step Therapy Exception Request (PDF, 1.4 MB)
    • Servicing Provider Change Request Form for Existing Authorization (PDF, 99 KB)
    • Skilled Nursing Facility service authorization request (PDF, 440 KB)
    • Standard drug or drug class prior authorizations request (Medicare) (DOCX, 231 KB)
  • Referral forms
    • Beacon Health Options (Behavioral Health Services) Primary Care Physician Referral (PDF, 107 KB)
    • Community Supports Referral (PDF, 523 KB)
    • Population Health Management / Case Management Referral (PDF, 57 KB)
    • Social Services Referral (PDF, 146 KB)
    • Maternity Care Referral (PDF, 83 KB)
    • Health Education Referral (PDF, 94 KB)
  • Other patient care forms
    • Age-appropriate Physical Evaluation Templates (PDF, 144 KB)
    • Appointment of Representative, English (PDF, 150 KB)
    • Appointment of Representative, Spanish (PDF, 335 KB)
    • Critical Incident Report (PDF, 403 KB)
    • Initial Health Assessment (IHA) Audit, Medi-Cal (PDF, 158 KB)
    • Lead Declination Form, English (PDF, 136 KB)
    • Lead Declination Form, Spanish (PDF, 122 KB)
    • Palliative Care Patient Eligibility Screening Tool (PDF, 449 KB)
    • Palliative Care Recertification Tool (PDF, 235 KB)
    • Pregnancy Notification Form-Medi-Cal Patients (PDF, 168 KB)
    • Provider Request Form for Medi-Cal Continuity of Care (PDF, 534 KB)
  • Claims and payments forms and templates
    • 10-Day Notice Fax Cover Sheet (DOCX, 185 KB)
    • 274+ Flat File Sample (XLSX, 31 KB)
    • Claims Fax Cover Sheet (PDF, 1 MB)
    • EDI Inquiry Form (online)
    • Medicare and Cal MediConnect Remittance Advice Format (XLSX, 126 KB)
    • Medi-Cal Remittance Advice Format (XLSX, 18 KB)
    • Provider Data Confirmation (PDC) Form (DOCX, 85 KB)
    • SNF Claims Billing Guide (PDF, 293 KB)
    • Third Party Liability (TPL) Fax Cover Sheet (DOCX, 185 KB)
  • Provider dispute forms
    • Provider Dispute Resolution Request (PDF, 522 KB)
    • Provider Dispute Resolution Request (multiple claims) spreadsheet (PDF, 116 KB)
    • Waiver of Liability (DOCX, 93 KB)

Medical care solutions

Review medical care solutions for Blue Shield Promise plans.

View and search the list of all clinical policies and procedures

Prior authorization list

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

View prior authorization list

Provider Connection

Access network provider tools on Provider Connection website.

Access Provider Connection

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Notices

  • Non-discrimination notice
  • Terms and conditions of use
  • Notice of privacy practices
  • TTY: 711
  • Medicare Sales: (800)963-8008 [TTY 711]. Available seven days a week 8 a.m. to 8 p.m. PST, From October 1 through February 14, and 8 a.m. to 8 p.m. weekdays, from February 15 through September 30.

Health Care Options: 1-844-580-7272, Monday through Friday from 8 a.m. - 6 p.m. TTY users should call 1-800-430-7077.

For information on Blue Shield Promise Cal MediConnect Plan and other Cal MediConnect options for your health care, call the Department of Health Care Services at 1-800-430-4263 (TTY: 1-800-735-2922), or visit https://www.healthcareoptions.dhcs.ca.gov/.

Blue Shield of California Promise Health Plan is a managed care organization, wholly owned by Blue Shield of California, offering Medi-Cal and Cal MediConnect Plans.

© 2002-2022. California Physicians’ Service DBA Blue Shield of California Promise Health Plan. All rights reserved.

California Physicians’ Service DBA Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association.

The provider network may change at any time. You will receive notice when necessary.

Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

Blue Shield of California Promise Health Plan cumple con las leyes estatales y las leyes federales de derechos civiles vigentes, y no discrimina por motivos de raza, color, país de origen, ascedencial, religión, sexo, estado civil, genero, identidad de genero, orientación sexual, edad ni discapacidad.

Blue Shield of California Promise Health Plan 遵循適用的州法律和聯邦公民權利法律,並且不以種族、膚色、原國籍、血統、宗教、性別、婚姻 狀況、性別認同、性取向、年齡或殘障為由而進行歧視。

Nondiscrimination notice

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Blue Shield of California Promise Health Plan, 601 Potrero Grande Drive, Monterey Park, CA 91755.

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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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