Clinical Guidelines and Shared Decision-making Aids

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


Shared decision-making aids
Providers can also utilize certified decision-making tools based on their specialty. These tools assist physicians in discussing treatment options with their members (conservative to invasive) and include information on risk and potential outcomes. Patient decision aids are available on the topics of maternity and labor/delivery; total joint replacement and spine care; end of life care; and cancer screening.

 View patient decision aids

 

Clinical practice guidelines

Condition Guideline Consensus Document
Asthma
Chronic Obstructive Pulmonary Disease (COPD) Global Strategy for Diagnosis Management and Prevention of COPD - 2019 (PDF, 9.7 MB)
ICSI Chronic Obstructive Pulmonary Disease Guideline. Revision Date: January 2016, 10th Ed.
GOLD Global Initiative for Chronic Obstructive Lung Disease
ATS Standards for the Diagnosis and Care of Patients with Chronic Pulmonary Obstructive Disease
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

ACCF/AHA Guideline for the Management of Heart Failure, 2017 October
2016 ACC/AHA/HSFA Focused Update on New Pharmacological Therapy for Heart Failure
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 customer 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

Medical care solutions

Review medical care solutions for Blue Shield Promise plans.

Prior authorization list

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

Pharmacy services and drug formularies

Review drug formularies for Cal MediConnect 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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