Getting care with Medicare

How do you find a doctor or therapist?

For Medicare Advantage Plans (HMO), our Dual Eligible Special Needs Plan (HMO D-SNP), and Medicare Supplement plans, find doctors and services by using our Find a doctor tool. You can search by name, facility, medical group, or specialty. Members can log in to their Blue Shield of California online account for the best results.

This does not apply to Prescription Drug Plan (PDP) members.

How can Blue Shield help you get earlier medical appointments?

If you have a Medicare Advantage Plan or Dual Eligible Special Needs Plan (D-SNP), you can get help from a Care Navigator. They work with provider offices to schedule earlier appointments. Call Customer Service and ask for a Care Navigator.

For Medicare Supplement plan members, Customer Service can help you with this as well.

How do you change your Primary Care Physician (PCP)?

Medicare Advantage Plans and our Dual Eligible Special Needs Plan members can get step-by-step instructions here or call Customer Service.

Please note this does not apply to Medicare Supplement plans or Prescription Drug Plans.

What is a referral?

For Medicare Advantage Plans and our Dual Eligible Special Needs Plan, a referral is a request from your PCP for an appointment with a specialist. A specialist is a provider who focuses on a specific disease or part of the body such as a surgeon or physical therapist.

Please note this does not apply to Medicare Supplement plans or Prescription Drug Plans.

When do you need a referral?

For Medicare Advantage Plans and our Dual Eligible Special Needs Plan, you need a referral if you have an HMO plan and need specialty care.

You don’t need a referral if you need emergency or urgent care. A referral is when your PCP requests an appointment for you with a specialist. This helps ensure the specialist:

• Knows why you’re coming
• Has your medical history
• Provides the right care

If you have a Medicare Advantage Plan or Dual Eligible Special Needs Plan, a Care Navigator can help you get referrals and find available specialists. Call Customer Service and ask to speak to a Care Navigator.

Please note this does not apply to Medicare Supplement plans or Prescription Drug Plans.

What is a prior authorization?

For Medicare Advantage Plans, our Dual Eligible Special Needs Plan, and Prescription Drug Plans, a prior authorization is a request for preapproval of certain tests, procedures, medical equipment, and medications ordered for you. Your provider must get that approval from Blue Shield before they proceed. 

The Blue Shield team will review the prior authorization request to ensure that Medicare covers everything and that the care meets the best clinical research available. Without this preapproval, Blue Shield may not pay for your medication, medical equipment, or medical procedure. You would then have to pay out of pocket.

Please note this does not apply to Medicare Supplement plans.

Who starts the prior authorization process and how do you track it?

For Medicare Advantage Plans, our Dual Eligible Special Needs Plan, and Prescription Drug Plans, typically, a provider starts the process by submitting a request on your behalf. The prior authorization will include details about your diagnosis and why the service or medication is needed. Prior authorizations usually take 1 to 3 days.

As a Blue Shield member, you have two ways to check if your prior authorization has been processed:

• Log in to your account. Under the “myblueshield” drop-down menu, select Prior authorization. Here you can see a list of all prior authorization requests, as well as those that Blue Shield has approved.
• Call Customer Service or your provider’s office. If you need help getting a prior authorization approved, call Customer Service at the number on your ID card.

Please note this does not apply to Medicare Supplement plans.

What if the prior authorization is denied?

As a Blue Shield member in a Medicare Advantage Plan, Dual Eligible Special Needs Plan, or Prescription Drug Plan, you have the right to appeal if Blue Shield denies your prior authorization request.

• If you have a Medicare Advantage Prescription Drug Plan, Dual Eligible Special Needs Plan, or Medicare Prescription Drug Plan, please visit our Appeals and grievances page.

Please note this does not apply to Medicare Supplement plans.