Prior authorization for treatment
What healthcare services are covered by Blue Shield of California Promise Health Plan?
For you to get any healthcare service through Blue Shield Promise Medi-Cal, the service must be both:
- A covered benefit in Medi-Cal, and
- Medically necessary
A "covered benefit" means that you can get this service through Medi-Cal and Blue Shield of California Promise Health Plan. "Medically necessary" means that you need the service to get healthy or to stay healthy. All healthcare services are reviewed, changed, approved, or denied according to medical necessity.
If you would like a copy of the policies and procedures Blue Shield of California Promise Health Plan uses to decide if a service is medically necessary, call Blue Shield of California Promise Health Plan. No provider has to give you services that he or she doesn't believe you need. Services are subject to all terms, conditions, limits, and exclusions. You can learn more in the "Non-covered Services: What does Medi-Cal not cover?" section of your Member Handbook.
What is prior authorization?
All services require prior authorization unless the benefit says that prior authorization is not needed.
"Prior authorization" means that your primary care physician (PCP) and Blue Shield of California Promise Health Plan agree that services and care are necessary. You must have a prior authorization before you get most services or care. For example, you need approval to see a specialist.
See the list of services requiring prior authorization
Healthcare services that do not require a referral or prior authorization (this is not a complete list):
- PCP visits
- Network certified nurse midwife OB/GYN visits
- Urgent or emergency care visits
- Family planning
- Basic prenatal care from a provider who works with Blue Shield Promise Medi-Cal
- HIV testing and counseling (persons 12 years or older)
- Treatment for sexually transmitted infections (persons 12 years or older)
Minors also do not need a referral for:
- Outpatient mental health for:
- Sexual or physical abuse
- When you may hurt yourself or others
- Pregnancy care
- Sexual assault care
- Drug and alcohol abuse treatment
See the "Covered Benefits" section in your Member Handbook (Evidence of Coverage) for a complete list or call Blue Shield Promise Medi-Cal Member Services at:
Phone: Los Angeles: (800) 605-2556 [TTY: 711], 8 a.m. – 6 p.m., Monday through Friday
Phone: San Diego: (855) 699-5557 [TTY: 711], 8 a.m. – 6 p.m., Monday through Friday
For emergencies, you can call the above numbers 24 hours a day, 7 days a week.
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