Policies and Guidelines
Learn more about submitting claims and rules for payment, including time frames for submitting, contesting or adjusting a claim as well as special guidelines for electronic and paper claim forms.
Ancillary claims filing guidelines
Review claim submission requirements for Blue Shield of California labs, specialty pharmacy and DME providers.
Special guidelines for claim forms
Special guidelines for CMS 1500 and UB-04 claims to help physicians submit these forms properly and process claims efficiently.
NCCI edits – physician and hospital outpatient
Review recent NCCI edits to physicians and hospital outpatient providers.
Payment policies and rules
Read an overview of payment processing policies and rules.
Medications
View listings of Richman Injectables (high-cost, adult, childhood, etc.), gene and cell therapy agents (including CAR-T), and behavioral health medications.
Claims and dispute resolution regulations
Review the DMHC regulations summary and a compliance overview.
National Drug Code requirements for physician administered drugs
Find requirements and drug list for claims and encounters for Promise Medi-Cal and Cal MediConnect members.