How to submit claims

The best way to submit claims and receive payment is to submit them electronically. Learn more about managing your claims with Blue Shield of California.  

Submitting claims
Prescreening claims
Correcting claims
Checking claim status and viewing Explanation of Benefits (EOBs) online
Contacting Provider Services
Disputing a claim decision

Submitting claims

For faster processing and payment, submit claims and receive payments electronically using electronic data interchange (EDI) or the Real-time claims tool. You can also submit via SimpliSend or by postal mail.
 

EDI

EDI allows paperless billing and payment for healthcare services and automates many routine inquiries. Enroll with Office Ally or use a clearinghouse of your choice.

To enroll in electronic payment options and learn more about using EDI, see our Manage electronic transactions page.
 

Real-time claims tool

Use the Real-time claims tool to submit medical and hospital claims for: 

• Blue Shield fully insured Commercial PPO members who have a single healthcare policy.
  
• HMO members when Blue Shield is financially responsible.
• Covered California members with Individual and Family Plans (IFP).

To start using the Real-time claims tool, ask your account manager to give you access. For more information about the Real-time claims tool’s estimator capabilities, refer to Prescreening claims.

SympliSend

Submit paper claims online with or without attachments using the SympliSend tool.

 How to use SympliSend Portal (PDF, 1 MB)

Postal mail

Mailing addresses can vary by plan type. If you need to submit paper claims for an out-of-area Blue plan member, use the Claims-routing tool to determine the correct mailing address. You can also browse our list of claims mailing addresses.

Prescreening claims

Prescreen claims to minimize your administrative costs and simplify doing business with us. Two tools are available:

The Real-time claims tool has an estimator feature that can prescreen and estimate claims in seconds. Estimates are valid for seven days. With Real-time claims, you can:

• Identify submission errors and provide cost share information before a claim is submitted
  
• Generate a current estimate by resubmitting the expired estimate
• Convert estimates to claims and submit them 

To get started review the Real-time claims FAQs (PDF, 106 KB)

Clear Claim Connection (C3) is a simulation tool that lets you view claim auditing rules, payment policies, and clinical rationales. It is available for professional and facility claims across Individual, Small Group, Employer Group, Medicare Advantage, Shared Advantage, FEP, and Medicare Supplement plans.

C3 lets you enter CPT and HCPCS test codes on mock claims and immediately view the audit result and reference the rationales. Note that C3 does not submit claims and does not guarantee member eligibility or claim payment.

To get started review the How to Prescreen Claims start guide (PDF, 541 KB)

Correcting claims

To correct a claim, re-submit it electronically. To avoid having the claim denied as a duplicate, wait for the original claim to be finalized before sending as a corrected claim. Be sure to indicate that it is a corrected claim. All claim corrections must be received within your contract’s timely filing period. Consult your Provider manual for additional information.

If a claim is finalized but additional information has been requested, you can attach documents to a claim on Provider Connection or upload them via the SimpliSend tool. SimpliSend also allows you to submit claims with attachments and itemization requests for claims in processing.

Checking claim status and viewing Explanation of Benefits (EOBs) online

You can search online on Provider Connection for claims submitted for Blue Shield, Blue Shield Promise, out-of-area Blue plans (BlueCard), and the Federal Employee Program (FEP). Search and filter for specific claims using member, provider, or claim data to download the claim EOB and view remittance advice. If receiving payment electronically, you can also use check/EFT number or amount and other payment information to find a claim.

Contacting Provider Services

Provider Services can help address claim adjustments, requests for claim information, or answer inquiries about claim decisions, procedures, and payment rules. They may alter original claim decisions. If you have questions about a claim, contact us via phone, chat, or postal mail.

Disputing a claim decision

We are committed to providing a fair and transparent provider dispute resolution process. 

Before you file a formal dispute for a claim, please see if there is a faster route to remedy your issue. You can check if additional information has been requested for the claim to be reprocessed, a claim correction can be done, or a payment rules clarification can be provided by Provider Services. 

If we’re not able to resolve your claim issue and you consider it necessary to file a dispute, start online.