View and download Blue Shield Promise medical policy treatment authorization request (TAR) forms.
- Actigraphy (PDF, 170 KB)
- Amniotic Membrane and Amniotic Fluid (PDF, 154 KB)
- Balloon Dilation of the Eustachian Tube (PDF, 166 KB)
- Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis (PDF, 157 KB)
- Behavioral Health Treatment (PDF, 197 KB)
- Bioengineered Skin and Soft Tissue Substitutes (PDF, 162 KB)
- Bone Morphogenetic Protein (PDF, 160 KB)
- Bronchial Thermoplasty (PDF, 168 KB)
- Bronchial Valves (PDF, 166 KB)
- Closure Devices for Patent Foramen Ovale and Atrial Septal Defects (PDF, 159 KB)
- Cooling Devices Used in the Outpatient Setting (PDF, 168 KB)
- Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone (PDF, 159 KB)
- Electromagnetic Navigational Bronchoscopy (PDF, 169 KB)
- Extracorporeal Shock Wave Treatment for Plantar Fasciitis (PDF, 172 KB)
- Gender Affirmation Surgery (PDF, 167 KB)
- General Treatment Authorization Request (PDF, 211 KB)
- High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bells Palsy (PDF, 169 KB)
- Hip Resurfacing (PDF, 159 KB)
- Home Cardiorespiratory Monitoring (PDF, 153 KB)
- Hyperbaric Oxygen Therapy (PDF, 164 KB)
- Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions (PDF, 168 KB)
- Low-Level Laser Therapy (PDF, 153 KB)
- Myocardial Strain Imaging (PDF, 169 KB)
- Orthopedic Applications of Platelet-Rich Plasma (PDF, 169 KB)
- Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome (PDF, 169 KB)
- Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti (PDF, 163 KB)
- Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain (PDF, 174 KB)
- Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence (PDF, 171 KB)
- Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome (PDF, 171 KB)
- Photodynamic Therapy for Choroidal Neovascularization (PDF, 154 KB)
- Reconstructive Services (PDF, 163 KB)
- Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer (PDF, 158 KB)
- Subtalar Arthroereisis (PDF, 171 KB)
- Surgical Deactivation of Headache Trigger Sites (PDF, 158 KB)
- Surgical Treatment of Femoroacetabular Impingement (PDF, 161 KB)
- Synthetic Cartilage Implants for Joint Pain (PDF, 171 KB)
- Treatment of Varicose Veins/Venous Insufficiency (PDF, 162 KB)
- Vertical Expandable Prosthetic Titanium Rib (PDF, 171 KB)
Medical care solutions
Review medical care solutions for Blue Shield Promise plans.
Prior authorization list
View the list of medical services and procedures requiring medical necessity review or supplemental documentation prior to payment.
Tips for submitting Medi-Cal claims
Learn about best practices for billing Medi-Cal claims.