Authorizations

Authorizations for Blue Shield HMO members

Check with the member’s assigned IPA for next steps.

If you’re referred back to Blue Shield or you are a contracted network provider, use Blue Shield’s AuthAccel tool or contact us for most requests, with the exception of certain services specified below under the authorizations that must be submitted through Evolent

Authorizations that must be submitted through Evolent

Commercial HMO members

Prior authorization requests for radiation oncology, medical benefit oncology drugs, advanced imaging, spine surgery, and pain management services must be submitted to Evolent for HMO members with a Blue Shield directly contracted primary care physician and Trio HMO members with a virtual primary care physician.
 

Medicare PPO members

Authorization submission to Evolent for the types of care listed below also apply to our Medicare PPO members

Authorizations to submit through Evolent:

• Radiation oncology: Submit prior authorization requests for radiation oncology administered in the outpatient and office setting using the Evolent provider portal. 
  
  
• Medical benefit oncology drugs: Submit prior authorization requests for medical benefit oncology drugs administered in the outpatient and office setting using the Evolent provider portal.
  
  Submit CAR-T drug requests administered in the inpatient, outpatient, and office setting using the Evolent provider portal.
  
  
• Submit prior authorization requests for advanced imaging, spine surgery, and pain management using the Evolent provider portal.
   

 
Authorizations for Blue Shield Promise (Medi-Cal) members

Medical and Medical Benefit Drugs

Check with the member’s assigned IPA for next steps.

If you’re referred back to Blue Shield or you are a contracted network provider, use Blue Shield’s AuthAccel tool or contact us. 
 

Outpatient/retail pharmacy

Since January 1, 2022, the state-run program Medi-Cal Rx began managing Medi-Cal pharmacy benefits. The Department of Health Care Services (DHCS) administers the Medi-Cal Rx program through their vendor, Magellan Rx. To learn more, visit the Medi-Cal Rx website any time or call (800) 977-2273, available 8 a.m. to 5 p.m. Pacific Time, Monday through Friday.

IPA authorization log

Submit logs of approvals, denials, and partial denials for a medical or pharmacy service through the IPA authorization log upload.