HMO benefit guidelines

This manual lists benefit details including coverage criteria, benefit exclusions, limitations and exceptions for HMO IPAs and medical groups that contract with Blue Shield of California. Examples of covered services and non-covered services pertaining to that topic may also be included. You can navigate the benefit guidelines by procedure, condition or administrative topic. You'll need Adobe Reader to view the forms.

Change notification

January 2025 HMO Benefit Guidelines change notification letter (PDF, 174 KB)
 

Optional benefits (group plan riders)

Acupuncture/chiropractic services (PDF, 30 KB)

Chiropractic services (PDF, 28 KB)

Dental HMO (PDF, 150 KB)

Dental PPO (PDF, 156 KB)

Infertility – additional benefits (PDF, 116 KB)

Vision care – VPA (PDF, 84 KB)
 

HMO benefit guidelines

Download the complete manual or view individual guidelines in PDF format:

Complete manual – January 2024 HMO benefit guidelines (PDF, 1.1 MB)

Cross reference index (PDF, 102 KB)

Forms

Download and print commonly requested patient care, prior authorization and network forms.

Find forms for Blue Shield of California providers

Find forms for Blue Shield Promise providers

Guidelines and procedures

Find operating guidelines for clinical practices, preventive health and procedures for continuing network participation.

Read guidelines

Policies and standards

Find medication policies information and standards for HIPAA transactions, medical records and more.

Read about our policies and standards

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

TRUSTe