Prior Authorization for Medical Treatment

What is covered: What kinds of health care can I get from Blue Shield of California Promise Health Plan?

In order for you to get any health care service through Blue Shield of California Promise Health Plan, 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 stay healthy. All health care services are reviewed, modified (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/she doesn't believe you need. Services are subject to all terms, conditions, limits and exclusions. You can learn more about this in the "Non-covered Services: What does Medi-Cal not cover?" section of the Member Handbook.

All services require prior authorization unless the benefit says that prior authorization is not needed.

"Prior authorization" means that your 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, such as services from a specialist.

Health Care Services that do not require a Referral or Prior Authorization (this is not a complete list)

  • Primary Care Provider visits
  • Emergency services
  • Family planning services
  • Preventive services
  • Sexually transmitted disease (STD) services
  • HIV testing
  • Basic prenatal care from a Provider who works with Blue Shield of California Promise Health Plan
  • In-network Certified Nurse Midwife/Ob-Gyn

Please see the "Covered Benefits" section in the Member Handbook for more information.

 

Call Blue Shield of California Promise Health Plan at (866) 820-6009 (Los Angeles County) or (855) 699-5557 (San Diego County) if you have questions about your benefits. The call is free. We are available Monday through Friday, 8:00 a.m. to 6:00 p.m. For emergencies, you can call this number 24 hours a day, 7 days a week.