Prior authorization list
The prior authorization list is a resource for providers that lists the designated medical and surgical services and select prescription drugs which require prior authorization under a Blue Shield of California Promise Health Plan medical benefit. This list also includes specific equipment, services, drugs, and procedures requiring review or supplemental documentation prior to payment authorization.
Prior authorization for the services listed below is highly recommended. If authorization was not obtained prior to the service being rendered, the service will likely be reviewed for medical necessity at the point of claim.
While the list below covers the medical services, drugs, and procedures that require authorization prior to rendering a service, Blue Shield Promise may require additional information after the service has been provided. If we require further information to process the payment, Blue Shield Promise’s Claims Department will request specific information at that time. Please include medical records when you respond to a request from Blue Shield Promise’s Claims Department.
Please review our clinical policies and procedures and verify that any service you are going to provide a Blue Shield Promise member is a covered benefit. You may review our medical policies online or contact Provider Services at (800) 468-9935, 6 a.m. to 6:30 p.m., Monday through Friday.
If prior authorization was obtained and you are submitting an offline (i.e., paper) claim, remember to attach a copy of the prior authorization letter.
Prior Authorization Code Lists
Medi-Cal/Cal MediConnect Prior Auth Codes
The documents below list prior authorization codes for Blue Shield Promise Medi-Cal and Cal MediConnect member services.
Prior authorization information for medications
Prior Authorization information for medications can be found here for Medi-Cal plans.
Medical care solutions
Review medical care solutions for Blue Shield Promise plans.
Utilization management and clinical practice guidelines
Utilization management (UM) and clinical practice guidelines define healthcare standards applicable to members and providers.
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.
Access network provider tools on Provider Connection website.