MEDI-CAL Providers

Providers

Welcome Providers

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

We Think the Same Way You Do.

Blue Shield of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) 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 Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) Network

The Blue Shield of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) 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 of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) 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 of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) 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 of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) 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 of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) 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 of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) Special Programs


Clinical Practice Guidelines Links


Behavioral Health 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 of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018), Initial Long Term Care Prior Authorization, TAR data, Authorization Processes, Payment Disputes, Claims, Case Management, Transportation, Continuity of Care, Important Information for Blue Shield of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) 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.


Service Authorization Request Form


Services:


Access to Care Standards

Care1st uses guidelines to ensure that its members have access to care:


Initial Health Assessment (IHA)


QI Annual Evaluations/ Program Goals

Care1st 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 of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018)’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 of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) and regulatory agencies. Blue Shield of California Promise Medi-Cal Health Plan (Care1st Health Plan until 12/31/2018) recommends a six section format


Affirmative Statement and Utilization Management Criteria

  • Affirmative Statement
  • Utilization Management and Clinical Practice Guidelines

Tobacco Cessation