Prior authorization requirements for out-of-area Blue Plan membersFind medical policy and general prior authorization requirements for your patients who are covered by an out-of-area Blue Plan. Show
Find requirements 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:
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You may also contact Blue Shield Promise Cal MediConnect Plan Customer Care at the number listed above and ask to obtain the total number of the plan's grievances, appeals, and exceptions. Part D Coverage DeterminationCoverage determinations are decisions that Blue Shield Promise Cal MediConnect Plan makes about your coverage of prescription drugs. You, your provider, or other prescriber can contact Customer Care at the number listed above
to request a coverage determination. Your provider may use the optional Drug Coverage Form to submit their requests. However, this form is not necessary to request a coverage determination. Blue Shield providers can submit medical and pharmacy authorizations online in AuthAccel. Blue Shield Promise providers can submit medical authorizations online, but pharmacy requests must faxed. The status of all medical and pharmacy requests can be viewed in AuthAccel for both Blue Shield and Blue Shield Promise members, regardless of how they are submitted. Below are instructions for using AuthAccel. Request a medical authorization (PDF, 329 KB) View medical authorization status (PDF, 272 KB) Request a pharmacy authorization (PDF, 251 KB) View pharmacy authorization request (PDF, 177 KB) AuthAccel frequently asked questions (PDF, 277 KB) Medical authorization requests – How to:
Pharmacy authorization requests – How to:
Determine if medical authorization is required for a Commercial/FEP PPO member.AuthAccel can tell you when a medical authorization is not required for a Blue Shield Commercial/FEP member or if it is delegated to another approver. Note, behavioral health falls under the medical benefit. When either is the case, completing and submitting the request in AuthAccel will result in an inquiry. You must complete the process and click the Submit button to secure an inquiry number. You can download and/or print the inquiry for your records. When medical authorization is required by Blue Shield, you can complete and submit the request in AuthAccel. Please see the Request a Medical Authorization (PDF, 329KB) instructions for additional detail. You can also view Blue Shield’s prior authorization list or contact Blue Shield of California Provider Services to determine if medical authorization is required. Determine if medical authorization is required for a Medicare, Medi-Cal, or Cal MediConnect member.While you can submit an authorization in AuthAccel for a Medicare, Medi-Cal or Cal MediConnect member, the system cannot tell you if the request is required or delegated. To determine if medical authorization is required for a Medicare member, please consult the prior authorization list or call Blue Shield of California Provider Services at (800) 541-6652. Note, behavioral health falls under the medical benefit. To determine if medical authorization is required for a Medi-Cal or Cal MediConnect member, please consult the Prior Authorization Code Lists located on the Prior authorization list page, or call Blue Shield Promise Health Plan at (800) 468-9935. Submit a medical authorization request and check status for all plan types.Medical authorizations for Blue Shield of California and Blue Shield Promise Health Plan members, including requests for behavioral health services, can be submitted online in AuthAccel. Medical authorization status can also be viewed online, regardless of how the request is submitted. Detailed instructions for how to submit medical authorizations and check their status in AuthAccel are available from the links above as well as from the AuthAccel online authorization training page. Additionally, medical authorization requests for Commercial/FEP PPO and Medicare members can be faxed, and in some cases, phoned in. To obtain a fax form, visit the Prior authorization forms page. For telephone contacts, please see the Blue Shield of California Member Authorizations section on the Authorization contacts page. Medi-Cal and Cal MediConnect medical authorization requests can also be faxed, and in some cases, phoned in. To obtain a fax form, visit the Provider forms page. For telephone contacts, please see the Blue Shield Promise Member Authorizations section on the Authorization contacts page. Determine if pharmacy authorization is required for a Commercial member.To determine if pharmacy authorization is required, navigate to the Blue Shield Outpatient drug formulary page and select the Blue Shield of California IFP, Small Group, Large Group, and Medicare formularies link.
For drug formulary information for Commercial and Medicare member outpatient prescription drugs and home self-administered injectables, call (800) 535-9481. Determine if pharmacy authorization is required for a Medicare, Medi-Cal, or Cal MediConnect member.To determine if pharmacy authorization is required, navigate to the Blue Shield Promise Pharmacy services and drug formulary page, scroll to the Drug Formularies section, and click the appropriate formulary link. For Medicare members, you will also need to select the member’s plan.
For drug formulary information for Medi-Cal and Cal MediConnect member outpatient prescription drugs and home self-administered injectables, call (800) 468-9935. Submit a pharmacy authorization for a FEP PPO member or check if one is required.CVS Caremark is the program administrator for FEP PPO member retail drugs and is responsible for assisting with prior authorization. Visit the Blue Cross Blue Shield Federal Employee Program Prescription Drugs page for formulary information and approval forms or call a number below:
Submit a pharmacy authorization for a Commercial or Medicare member and check statusBlue Shield providers that utilize the Surescripts® or CoverMyMeds® EHR platforms and have electronic prior authorization (ePA) functionality enabled on their systems, can submit ePA for their patients to request outpatient drug prior authorization. This capability provides a real-time response for drug authorizations at point of care. ePA can also identify drugs that do not require prior authorization and eliminate the need to complete and submit paper forms. Additionally, providers can access CoverMyMeds from this website. Pharmacy authorization requests for Commercial and Medicare members can also be faxed to Blue Shield. Please see the Prescription drug prior authorization and step therapy exception request forms section on the Prior authorization forms page. For drug formulary information and to request prior authorization for Commercial and Medicare member outpatient prescription drugs and home self-administered injectables, call (800) 535-9481. Submit a pharmacy authorization for a Medi-Cal or Cal MediConnect member and check status.Blue Shield Promise providers that utilize the Surescripts® or CoverMyMeds® EHR platforms and have electronic prior authorization (ePA) functionality enabled on their systems, can submit ePA for their patients to request outpatient drug prior authorization. This capability provides a real-time response for drug authorizations at point of care. ePA can also identify drugs that do not require prior authorization and eliminate the need to complete and submit paper forms. Additionally, providers can access CoverMyMeds from this website. Pharmacy authorization requests for Medi-Cal and Cal MediConnect members can also be faxed to Blue Shield Promise. Please see the Authorization request forms section on the Provider forms page. For drug formulary information and to request prior authorization for Medi-Cal and Cal MediConnect member outpatient prescription drugs and home self-administered injectables, call (800) 468-9935. What form do providers in California use to request prior authorization for services?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.
What is the fax number for Anthem Blue Cross of California?Phone: Call 1‑888‑831‑2246, option 3 and ask for a form to be faxed to you. Fax: Send your request to: 1-800-754-4708. Anthem Blue Cross is the trade name of Blue Cross of California.
Why is it important for providers to submit claims with the correct prefix?Three-character prefix: The three-character prefix on the member's ID card is the key element used to identify the plan to which the member belongs and to correctly route claims. It is critical to confirm membership, eligibility and coverage.
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Blue shield of california prior authorization phone number
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