Special Guidelines for Claim Forms

CMS 1500 – Professional claim form special billing guidelines and procedures

 Review the 837 Claim Companion Guide for additional submission information

 CMS 1500 - Professional Claim form (PDF, 198 KB)

 CMS 1500 completion instructions (PDF, 78 KB)
 

Electronic submissions

For faster processing and turnaround, please submit all claims electronically. You may submit electronic claims directly to Blue Shield of California and Blue Shield of California Promise Health Plan using EDI, or online through an approved clearinghouse. Find more information about electronic claims submission.

If you have questions about electronic claim submission, please review the Electronic Data Interchange (EDI) Program information, contact our Electronic Data Interchange team.
 

Paper submissions

Please use original red claim forms for all paper claims. Blue Shield of California and Blue Shield Promise uses Optical Character Recognition (OCR) to scan paper claims. Claims submitted on photocopied claim forms prevent the OCR process from working properly, necessitating manual data entry of the claim, which can slow down processing and payment.

The appropriate claims mailing addresses can always be found online from the member's eligibility information.
 

Additional claims submission pointers

 837 Companion Guide

To expedite the processing of your claims, here are some additional claims submission pointers:

• When billing for drugs, supplies and equipment, use HCPCS codes.
• Use the most current ICD-10-CM for coding all diagnoses, including mental disorders.
• Identify diagnoses as precisely as possible. To expedite claim processing, always use four-digit codes, unless there is none in the particular coding category, and add a fifth digit sub-classification code whenever one exists.
• To ensure proper eligibility, obtain a copy of the Subscriber's Blue Shield of California or Blue Shield Promise ID card to verify the correct subscriber name, number and employer group information. Verify eligibility online.
• For correct benefit consideration, report same-day services for the same patient on the same claim. If services exceed more than six detail lines, use separate forms. In order to ensure that multiple forms are processed as a single claim, enter "continued" or "Page 1 of 2" in the Total Charges field.
• List the correct modifiers with the appropriate CPT code (e.g., modifiers to define the procedure or visit).

Blue Shield of California and Blue Shield Promise processing system allows up to a maximum of 20 detail lines per professional claims.

• Hospitals must submit professional services on a CMS 1500 claim form. You may no longer bill these services under revenue codes using the hospital's facility PIN on a UB-04 (or successor) claim form. All Blue Shield of California and Blue Shield Promise hospitals must establish a professional PIN to bill for these services.
• Blue Shield of California and Blue Shield Promise may require additional documentation to complete the processing of a claim. The documentation should be complete and legible. Types of documentation may include but are not limited to:
  • operative reports
  • emergency room reports
  • consultant reports
  • test records
  • facility records
  • NIA authorization

UB-04 – Institutional claim form special billing guidelines and procedures

UB-04 Institutional claim form (PDF, 216 KB)

UB-04 completion instructions (PDF, 95 KB)

Note: Hospitals billing on behalf of physicians should submit claims for physician services on a CMS 1500, not on the UB-04 (or successor) form. These services are not contracted under the hospital agreement and, therefore, will be rejected if submitted for payment on the UB-04 (or successor) form.
 

Electronic submissions

All hospitals can submit their claims electronically for faster processing. Refer to the HIPAA ANSI Implementation Guides, the National Uniform Billing Committee (NUBC) UB-04 Data Element Specifications, and the Blue Shield of California and Blue Shield Promise 837 Transaction Companion Guide for detailed instructions on electronically submitted claims.

You may submit claims electronically through a direct connection to Blue Shield of California and Blue Shield Promise, or online through an approved clearinghouse. Find more information about electronic claims submission.

To ensure efficient processing, Blue Shield of California and Blue Shield Promise may require additional information for the following types of claims:

• Adjustment Claims
• Exception Claims,* including, but not limited to:
  • Stop-Loss
  • Implants
  • Trauma
  • Transplants
• Medicare supplement claims
• Other Organ transplant claims
• Claims for inpatient admissions with covered and non-covered days during the same stay
• Late discharge (Documentation of medical necessity must be attached to the claim form.)

*This list of claims is not all-inclusive. For all exceptions, please refer to your hospital contract.
 

Paper submissions

Note: For faster processing and turnaround, please submit all claims electronically.

Please use original red claim forms for all paper claims. Blue Shield of California and Blue Shield Promise use Optical Character Recognition (OCR) to scan paper claims. Claims submitted on photocopied claim forms prevent the OCR process from working properly, necessitating manual data entry of the claim, which can slow down processing and payment.

The appropriate claims mailing addresses can always be found online from the member's eligibility information.
 

Other required billing information

Outpatient Charges
Submit outpatient claims on the UB-04 (or successor) claim format. Use appropriate Revenue, CPT/HCPCS Codes and modifiers for the following outpatient services:

• Surgical Services
• Emergency Services and Urgent Care Services
• Dialysis Services
• Infusion Therapy Services
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Respiratory Therapy
• Radiology/Pathology/Diagnostic Tests
• Clinical Laboratory Services
• Pharmaceutical Services
• All Other Outpatient Services

Enter the codes in Form Locator 44. Be sure to include all applicable Revenue, CPT/HCPCS Codes and modifiers. Refer to "Reimbursement for Outpatient Services," in the Hospital and Facility Guidelines for reimbursement details around each outpatient service. In accordance with national billing guidelines, Blue Shield requires the use of detailed, specific codes instead of generic, general codes.

Professional Charges
Hospitals that act as the billing agent for hospital-based physicians (i.e., emergency room physicians, clinic physicians, anesthesiologists, radiologists, pathologists, etc.) and other allied health professionals must obtain a separate nine-digit Blue Shield professional provider identification number (PIN) for both group and individual providers to bill for these services.

Skilled Nursing Facility Charges
Hospital and free-standing skilled nursing facility services must be billed on the UB-04 (or successor) claim form with the appropriate Revenue Code and CPT/HCPCS Codes to indicate the level of care or identified excluded service.

Dialysis Charges
Free-standing dialysis center services must be billed on the UB-04 (or successor) claim form with the appropriate Revenue Code, CPT/HCPCS Codes and modifiers in order to receive payment for services rendered.

Hospitals must submit claims for professional charges on a CMS 1500 paper form and must include not only the billing agent PIN, but also the PIN of the provider who performed the service. Block 24J of the CMS 1500 Form is the appropriate location for showing the rendering provider PIN. Please note that for Blue Shield Medicare Advantage claims, the rendering physician's state license or UPIN must be entered in this field.