Providers | Blue Shield of California Promise Health Plan

Providers

Please Note:

For your convenience, we now have a NEW dedicated provider line: (800) 468-9935.
If you have questions on electronic claim submissions, EDI 837/835 files, please click here to submit an online EDI Inquiry. (Please note, this will take you to the Blue Shield of California Promise Health Plan Provider website.)

Name Change and Data Migration Information and Resources

On January 1, 2019, Care1st changed its name to Blue Shield of California Promise Health Plan. We also moved member and provider data into new systems to better support our IT infrastructure. As a result of this name change and data migration, there have been many changes, some of which require action on your part over the next few months as we settle into our new processes.

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 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 of California Promise Health Plan network comprises over 7,000 physicians, 80 hospitals and many ancillary medical professionals. Our Provider Services department develops and manages the Blue Shield of California Promise Health Plan provider network throughout our service areas. With our information systems, Internet accessibility and experienced management support, we strive to achieve optimal provider satisfaction.

Provider Services 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 Health Plan 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 Health Plan 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 Health Plan 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.


Materials and Forms


Blue Shield of California Promise Health Plan Special Programs


Clinical Practice Guidelines Links


Nursing Facilities Reference Guide


Physicians Certification Form – Request for Transportation


Access to Care Standards

Blue Shield of California Promise Health Plan uses guidelines to ensure that its members have access to care:

Initial Health Assessment (IHA)


QI Annual Evaluations/ Program Goals

Blue Shield of California 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.

Medical Record Documentation Standards

Blue Shield of California Promise Health Plan’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 Health Plan and regulatory agencies. Blue Shield of California Promise Health Plan recommends a six section format


Affirmative Statement and Utilization Management Criteria

  • Affirmative Statement
  • Utilization Management and Clinical Practice Guidelines

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If you enter the web site CMS (Centers for Medicare & Medicaid Services) (http://www.cms.gov), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the CMS (Centers for Medicare & Medicaid Services) web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site. If you enter the web site California Department of Health Care Services (DHCS) (https://www.healthcareoptions.dhcs.ca.gov/), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the California Department of Health Care Services (DHCS) web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site. If you enter the web site Medi-Cal Dental Program (https://www.denti-cal.ca.gov/), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the Medi-Cal Dental Program web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site. If you enter the web site Solera4me (https://www.solera4me.com/bluepromisemedicare), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the Solera4me web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site. If you enter the web site Department of Managed Healthcare (http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx), please be aware that you will leave Blue Shield of California Promise Health Plan's web site, and will be routed to the Department of Managed Healthcare web site that adheres to the rules, policies, regulations and terms of use of that Organization. Blue Shield of California Promise Health Plan makes no representation and is not responsible for the quality, content, nature, or reliability of any linked site.