BCBS AFFILIATECAPBM: CVS Caremark

Blue Shield of California Prior Authorization Guide

Submit prior authorization requests and appeal denials with Blue Shield of California. Phone numbers, fax numbers, appeal deadlines, step therapy override rights, and clinical documentation tips for CA providers.

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Prior Authorization Contacts

PA PHONE

1-800-541-6652

PA FAX

1-888-397-4498

TURNAROUND

5 business days standard (CA law), 72h expedited

TIMELY FILING

365 days

APPEALS MAILING ADDRESS

Blue Shield of California, PO Box 272540, Chico, CA 95927

Common Denial Reasons

⚠ Medical policy criteria not met
⚠ Step therapy — generic or preferred brand not tried
⚠ California Knox-Keene Act PA requirements
⚠ Non-formulary without exception

Step Therapy Requirements & Override Rights

California SB 235 (2021) and AB 347 (2018) provide strong step therapy override rights. Blue Shield CA must respond within 72 hours urgent / 5 business days standard. California also has some of the strongest patient protection laws in the country.

Tips for Blue Shield of California Submissions

1. California has 365-day timely filing — longest in the country
2. SB 235 and AB 347 protect against unreasonable step therapy
3. Blue Shield CA is separate from Anthem Blue Cross CA — don't confuse them
4. Submit via the Blue Shield provider portal

External Review Authority

If Blue Shield of California denies your final internal appeal, you have the right to request an external review through: California Department of Managed Health Care (DMHC) IMR process.

External review decisions are binding on the insurer.