Providers | Blue Shield Promise Health Plan

Providers

Please Note:

For your convenience, we now have a NEW dedicated provider line: (800) 468-9935.

Name Change and Data Migration Information and Resources

On January 1, 2019, Care1st will be changing its name to Blue Shield of California Promise Health Plan. Also, on January 1, 2019, Care1st will be moving member and provider data into new systems to better support our IT infrastructure.
As a result of this name change and data migration upcoming, there will be many changes, some of which will require action on your part.
This page will keep you informed with the latest updates.

Access the latest updates, information and resources available.


Provider Login Assignment Form
You will have the ability to access Member Eligibility, Claims and Authorizations online with the login and password provided upon completion of the form. Understand that HIPAA requirements and guidelines should be adhered to and any discovery of mishap will be reported.

We Think the Same Way You Do.

Blue Shield of California Promise Health Plan (Blue Shield Promise) is led by physicians with active practices in Southern California.

Here, you'll find a level of understanding and communication that helps both your practice and your patients. And since we're directed by doctors, we have a "patients first" philosophy of care.

Welcome to the Blue Shield of California Promise Health Plan Network

The Blue Shield Promise network comprises over 7,000 physicians, 80 hospitals and many ancillary medical professionals. Our Provider Network Operations (PNO) department develops and manages the Blue Shield Promise provider network throughout our service areas. With our information systems, Internet accessibility and experienced management support, we strive to achieve optimal provider satisfaction.

PNO understands the importance of developing and maintaining solid relationships with providers as well as the barriers that the under-served population face in accessing health care services. As a mixed-model HMO, Blue Shield Promise contracts with individual physicians and Medical Groups/IPAs on a capitated basis. Under the Medical Group/IPA arrangements, many operational functions are delegated with Blue Shield Promise providing oversight.

Working closely with you.

Our mixed model also offers an opportunity for independent physicians and other provider types to contract directly with Blue Shield Promise under flexible reimbursement methodologies. It is our desire to be responsive and to work closely with our providers to better understand the challenges facing them. Our objective is to help providers improve the delivery of health care services.


Provider Notifications/Updates (NCQA)


Blue Shield Promise Special Programs


Clinical Practice Guidelines Links


Nursing Facilities Reference Guide

  • Nursing Facilities Reference Guide
    Verifying member eligibility, Determining responsible party for authorization and payment, Submitting Prior Authorization Requests to Blue Shield Promise, Initial Long Term Care Prior Authorization, TAR data, Authorization Processes, Payment Disputes, Claims, Case Management, Transportation, Continuity of Care, Important Information for Blue Shield Promise Health Plan and more...

Treatment Authorization Request Form

SNF Transportation Request Form (San Diego)

Skilled Nursing Facilities please complete the forms in legibly and in their entirety.
All Information is necessary to arrange transport.


Physicians Certification Form – Request for Transportation


Service Authorization Request Form


Services:


Access to Care Standards

Blue Shield Promise uses guidelines to ensure that its members have access to care:


Initial Health Assessment (IHA)


QI Annual Evaluations/ Program Goals

Blue Shield Promise Health Plan administers a robust ongoing Quality Improvement Program with a goal to ensure that members receive the highest quality of care and services.


2016 Quality Improvement Program Descriptions

Providing an effective, system-wide, measurable plan for monitoring, evaluating and improving the quality of care and services:


Medical Record Documentation Standards

Blue Shield Promise’s goal is to assure each patient has a legible, detailed, well organized, confidentially stored, and easily retrievable medical record. These records need to be consistent with standard medical and professional practice and meet the standards of oversight organizations, including Blue Shield Promise Health Plan and regulatory agencies. Blue Shield Promise Health Plan recommends a six section format


Affirmative Statement and Utilization Management Criteria

  • Affirmative Statement
  • Utilization Management and Clinical Practice Guidelines

Tobacco Cessation

You are leaving Promise Health Plan's website

If you enter the web site of Krames on Demand (http://kod.staywellsolutionsonline.com/?accountId=0), please be aware that you will leave Promise Health Plan's web site, and will be routed to the Krames on Demand's web site that adheres to the rules, policies, regulations and terms of use of that service.


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