Blue shield of california prior authorization form pdf

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.

Table of Contents Show

Prior Authorization Code Lists
Information for physicians
What form do providers in California use to request prior authorization?
How do I submit a prior authorization to Medi Cal?
How long does preauthorization take for surgery?
What is the timely filing for Blue Shield of California?

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.

Medi-Cal/Cal MediConnect Prior Auth Code List - September 2022 (PDF, 407 KB)

Medi-Cal/Cal MediConnect Prior Auth Code List - June 2022 (PDF, 386 KB)

Medi-Cal/Cal MediConnect Prior Auth Code List - February 2022 (PDF, 586 KB)

Medi-Cal/Cal MediConnect Prior Auth Code List - December 2021 (PDF, 570 KB)

Medi-Cal/Cal MediConnect Prior Auth Code List - August 2021 (PDF, 483 KB)

Prior authorization information for medications

Prior Authorization information for medications can be found here for Medi-Cal plans.

Some procedures, medical and surgical services, specific equipment, and select prescription drugs require prior authorization. A prior authorization is an approval review that Blue Shield of California Promise Health Plan conducts.

To request prior authorization for treatment or for a drug, you, your doctor, other prescriber, or appointed representative need to contact Blue Shield of California Promise Health Plan and provide necessary clinical information. If this information is not submitted or does not meet the prior authorization criteria, the Health Plan may not cover the service or drug.

For a prior authorization request to be considered for approval, a doctor must provide clinical information which may include, but is not limited to, the following:

The diagnosis or reason(s) you are receiving the drug treatment
Lab test information (for example, LDL level for cholesterol treatment, or the hemoglobin A1c level for diabetes treatment)
Your doctor's specialty
Whether you have been evaluated by a specialist
or
Other treatment(s) that have been attempted and whether they were effective
Whether you experienced side effect from a particular treatment
Required dosage and the estimated length of your expected treatment
or
Whether a generic drug alternative may be medically appropriate for you.

See the list of services requiring prior authorization

To request assistance with a prior authorization request, please call Blue Shield of California Promise Health Plan Member Services:

Phone:(800) 544-0088 [TTY: 711], 8 a.m. – 8 p.m., seven days a week from October 1 through March 31, and 8 a.m. – 8 p.m., weekdays from April 1 through September 30.

You may also contact Member Services at the number listed above and ask to obtain the total number of the plan's grievances, appeals, and exceptions.

Information for physicians

Providers and prescribers can contact Pharmacy Services to request a coverage determination. They may use optional Physicians' Treatment or Drug Prior Authorization Forms to submit their requests. However, these forms are not necessary to request a coverage determination.
Phone:(800) 468-9935, [TTY: 711], Monday – Friday, 6 am – 6:30 pm.

Prescription drug prior authorizations or step therapy exception request form (PDF, 138 KB)

Standard drug or drug class prior authorizations request form (DOCX, 231 KB)

Physicians' treatment prior authorization forms

Treatment referral form (PDF, 128 KB)

What form do providers in California use to request prior authorization?

Providers must request CCS services using a SAR form. Note: Providers should verify CCS eligibility before submitting a SAR. Providers are required to submit documentation to substantiate medical necessity at the time the SAR is submitted.

How do I submit a prior authorization to Medi Cal?

Pharmacy providers and prescribers can submit a PA request via fax by utilizing the following approved forms: 50-1, 50-2, 61-211, or the Medi-Cal Rx PA Request Form, available January 1, 2022, in Reference Materials at www.medi-calrx.dhcs.ca.gov/provider/forms/.

How long does preauthorization take for surgery?

Typically, within 5-10 business days of receiving the prior authorization request, your insurance company will either: Approve your request. Deny your request.

What is the timely filing for Blue Shield of California?

Initial Appeals must be submitted within 365 days, or the time specified in the provider's contract, whichever is greater, of Blue Shield's date of contest, denial, notice or payment.