View and download Blue Shield Promise medical policy treatment authorization request (TAR) forms.
Treatment authorization request forms
- Form Title
- Actigraphy
- Amniotic Membrane and Amniotic Fluid
- Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
- Balloon Dilation of the Eustachian Tube
- Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
- Behavioral Health Treatment
- Bioengineered Skin and Soft Tissue Substitutes
- Bone Morphogenetic Protein
- Bronchial Thermoplasty
- Bronchial Valves
- Carrier Screening for Genetic Diseases
- Cartilage Implants for Joint Pain
- Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss
- Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
- Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
- Cooling Devices Used in the Outpatient Setting
- Cosmetic and Reconstructive Procedures
- Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
- Electromagnetic Navigational Bronchoscopy
- Extracorporeal Shock Wave Treatment for Plantar Fasciitis
- Gender Affirmation Surgery
- Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
- Gene Expression Profiling for Cutaneous Melanoma
- Gene Expression Profiling, Protein Biomarkers, and Multimodal Artificial Intelligence for Prostate Cancer Management
- General Approach to Evaluating the Utility of Genetic Panels
- General Approach to Genetic Testing
- General Transplant Authorization Request
- General Treatment Authorization Request
- Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
- Genetic Testing for Alzheimer Disease
- Genetic Testing for Cardiac Ion Channelopathies
- Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies
- Genetic Testing for Diagnosis and Management of Mental Health Conditions
- Genetic Testing for Epilepsy
- Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
- Genetic Testing for Mitochondrial Disorders
- Genetic Variant Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer
- Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
- High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy
- Hip Resurfacing
- Home Cardiorespiratory Monitoring
- Hyperbaric Oxygen Therapy
- Identification of Microorganisms Using Nucleic Acid Probes
- Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
- Invasive Prenatal (Fetal) Diagnostic Testing
- Laboratory Testing Not Medically Necessary Services
- Low-Level Laser Therapy
- Molecular Genomic Profiling for Cancers of Unknown Primary
- Multimarker Serum Testing Related to Ovarian Cancer
- Myocardial Strain Imaging
- Orthopedic Applications of Platelet-Rich Plasma
- Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome
- Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti
- Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain
- Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
- Percutaneous Electrical Nerve Field Stimulation for Disorders of Gut-Brain Interaction
- Photodynamic Therapy for Choroidal Neovascularization
- Preimplantation Genetic Testing
- Reconstructive Services
- Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
- Skeletal Remodeling
- Subtalar Arthroereisis
- Surgical Deactivation of Headache Trigger Sites
- Surgical Treatment of Femoroacetabular Impingement
- Synthetic Cartilage Implants for Joint Pain
- Treatment of Varicose Veins/Venous Insufficiency
- Tumor Treating Fields Therapy
- Tumor-Informed Circulating Tumor DNA Testing (Signatera™) for Cancer Management
- Tumor-Uninformed Circulating Tumor DNA (Guardant Reveal™) for Cancer Management (Liquid Biopsy)
- Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer
- Vertical Expandable Prosthetic Titanium Rib
- Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
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.
Provider Connection
Access network provider tools on Provider Connection website.