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)
HMO Benefit Guidelines list
Benefit summaries
Forms
Download and print commonly requested patient care, prior authorization and network forms.
Guidelines and procedures
Find operating guidelines for clinical practices, preventive health and procedures for continuing network participation.
Policies and standards
Find medication policies information and standards for HIPAA transactions, medical records and more.