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Prior Authorization Reimagined

Get care answers in near real-time

Prior authorization helps health plans ensure certain recommended treatments and services are safe, evidence-based and high-value. Prior authorization has become cumbersome and inefficient in part due to outdated healthcare industry technology, including fax machines.

Blue Shield of California is teaming up with Salesforce to make prior authorization quick and easy while enabling more coordinated, personalized support for members.

Modifications or denials will always be made by a medical director or licensed clinician.   

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Pushing the boundaries on what's possible

Our high-tech, high-touch system will:

  • Streamline 20+ disparate systems into one process
  • Use Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) standards to integrate into physicians' current workflow
  • Provide portal access for non-HL7 compatible systems
  • Search a patient's electronic health record for clinical information relevant to the prior authorization request when prompted by a physician
  • Return answers in near real-time in most cases

Testing begins in early 2025 with limited rollout later in year. Near real-time prior authorization available to all physicians in January 2026. Additional capabilities to follow. 

Video

Experience Prior Authorization Reimagined

Take a tour of our vision for what prior authorization should be.

Wellvolution Apps

Enabling more holistic, comprehensive care

The new platform solution will work alongside Care Connect — Blue Shield's award-winning care management system — to enable more personalized, coordinated care. In the future, a prior authorization request will automatically alert the health plan's team of nurses, social workers and behavioral health specialists that a member may need new or increased health support.

Health Reimagined — A bold vision to transform health care

Health Reimagined is Blue Shield's vision to transform the healthcare industry into one that works for members and providers. This means making prescriptions and treatments affordable, enabling care teams and members to make decisions based on data and preference, rewarding high-quality care, and creating a digital experience that has members' health information all in one place to prioritize their care and wellness — bringing the healthcare system into the modern age.

This is just the beginning