Prior authorization list

The prior authorization list is a resource for providers that lists the designated medical and surgical services and select prescription drugs which require prior authorization under a Blue Shield of California Promise Health Plan medical benefit. This list also includes specific equipment, services, drugs, and procedures requiring review or supplemental documentation prior to payment authorization.

Prior authorization for the services listed below is highly recommended. If authorization was not obtained prior to the service being rendered, the service will likely be reviewed for medical necessity at the point of claim.

While the list below covers the medical services, drugs, and procedures that require authorization prior to rendering a service, Blue Shield Promise may require additional information after the service has been provided. If we require further information to process the payment, Blue Shield Promise’s Claims Department will request specific information at that time. Please include medical records when you respond to a request from Blue Shield Promise’s Claims Department.

Please review our clinical policies and procedures and verify that any service you are going to provide a Blue Shield Promise member is a covered benefit. You may review our medical policies online or contact Provider Services at (800) 468-9935, 6 a.m. to 6:30 p.m., Monday through Friday.

If prior authorization was obtained and you are submitting an offline (i.e., paper) claim, remember to attach a copy of the prior authorization letter.

Effective January 1, 2023, Cal MediConnect plans were discontinued throughout California. Blue Shield Promise Cal MediConnect members in Los Angeles and San Diego counties were transitioned to the Blue Shield TotalDual (HMO D-SNP) plan.

Prior authorization code lists

Medi-Cal/Cal MediConnect prior authorization codes
The documents below list prior authorization codes for Blue Shield Promise Medi-Cal and Cal MediConnect member services.

 Medi-Cal Prior Auth Code List – May 2024 (PDF, 422 KB)

 Medi-Cal Prior Auth Code List – April 2024 (PDF, 415 KB)

 Medi-Cal Prior Auth Code List – March 2024 (PDF, 413 KB)

 Medi-Cal Prior Auth Code List – February 2024 (PDF, 462 KB)

 Medi-Cal Prior Auth Code List – January 2024 (PDF, 462 KB)

 Medi-Cal Prior Auth Code List – December 2023 (PDF, 449 KB)

 Medi-Cal Prior Auth Code List – November 2023 (PDF, 449 KB)

 Medi-Cal Prior Auth Code List – October 2023 (PDF, 634 KB)

 Medi-Cal Prior Auth Code List - September 2023 (PDF, 636 KB)

 Medi-Cal Prior Auth Code List – August 2023 (PDF, 299 KB)

 Medi-Cal Prior Auth Code List – July 2023 (PDF, 642 KB)

 Medi-Cal Prior Auth Code List – June 2023 (PDF, 473 KB)

 Medi-Cal Prior Auth Code List – May 2023 (PDF, 839 KB)

 Medi-Cal Prior Auth Code List – April 2023 (PDF, 692 KB)

 Medi-Cal Prior Auth Code List – February 2023 (PDF, 685 KB)

 Medi-Cal/Cal MediConnect Prior Auth Code List – December 2022 (PDF, 479 KB)

 Medi-Cal/Cal MediConnect Prior Auth Code List – September 2022 (PDF, 407 KB)

 Medi-Cal/Cal MediConnect Prior Auth Code List – June 2022 (PDF, 386 KB)

 Medi-Cal/Cal MediConnect Prior Auth Code List – February 2022 (PDF, 586 KB)

 Medi-Cal/Cal MediConnect Prior Auth Code List – December 2021 (PDF, 570 KB)

 Medi-Cal/Cal MediConnect Prior Auth Code List – August 2021 (PDF, 483 KB)

Prior authorization information for medications

Prior Authorization information for medications can be found here for Medi-Cal plans.

Medical care solutions

Review medical care solutions for Blue Shield Promise plans.

Utilization management and clinical practice guidelines

Utilization management (UM) and clinical practice guidelines define healthcare standards applicable to members and providers.

Pharmacy services and drug formularies

Access drug formularies and find pharmacy services information.

Prior authorization and referral forms

Find common forms which you may need to request prior authorization, as well as patient referral forms.

Provider Connection

Access network provider tools on Provider Connection website.

Health Care Options: (844) 580-7272  {TTY: {800) 430-7077}, Monday through Friday from 8 a.m. — 6 p.m. 

For information on Blue Shield Promise plans for your health care, call the Department of Health Care Services at (800) 430-4263 {TTY: (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 Plans.

© 2002-2024. 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。

 

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Blue Shield of California Promise Health Plan, 3840 Kilroy Airport Way, 
Long Beach, CA  90806

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