EDI, ERA/EFT, and Secondary 277CA FAQs

To allow electronic payments, fill out the Provider authorization form (PDF, 173 KB).

No, Blue Shield of California does not charge providers to submit EDI claims.

Software vendors must be approved by Blue Shield of California through a testing process (PDF, 46 KB).

Only clearinghouses approved by Blue Shield of California (PDF, 82 KB) may be used to connect to Blue Shield of California.
 

Blue Shield of California Promise Health Plan providers must use this approved clearinghouse:

OfficeAlly
Payer ID: C1SCA
(866) 575-4120
www.officeally.com

Validation reports for claims submitted directly to Blue Shield using Secure File Transfer Protocol (SFTP) are available for retrieval from your folder the following business day. 

Please contact your vendor to request validation reports for claims you submitted through an electronic clearinghouse. 

The most common reasons that claims fail are:

• No subscriber record on file for subscriber number
• No provider number
• Duplicate claim
• Related procedure in history is unbundled
• Provider type and specialty not valid for procedure billed
• Unauthorized or invalid submitter ID

Yes, all electronic claims submissions must include the NPI number. Providers and facilities can obtain an NPI from National Plan and Provider Enumeration System (NPPES) at (800) 465-3203 or on their website.

Corrected claims should be sent electronically after the original claim has finalized to avoid denial as a duplicate. Re-bill corrected claims with the appropriate adjustment bill type.

Be sure to include the following EDI segments on your adjusted claim: 

• Send F8 in REF01 (Loop 2300)

• Send 14 digit number BSC ICN of incorrect original claim in REF02 (Loop 2300)

  Sample: REF*F8*12345678912345~

  Note: 12345678912345 should be replaced with the original claim's Blue Shield of California internal control number (ICN).

  You can find the Blue Shield of California internal control number (ICN) using the online claim status search or from the explanation of benefits (EOB) or electronic remittance advice (ERA).

On professional EDI claims: 

• Copy SELF REFERRAL to NM103 (Loop 2310A) 
• Submit REF segment in Loop 2310A, with "1B" in REF01 and "SLF000" as REF02 NM102 = 2 NM103 = SELFREFERRAL
  
  Sample: NM1*DN*2*SELFREFERRAL*****XX*1002233777~ REF*1B*SLF000~ 

On Institutional EDI claims: 

• Copy SELF to NM103 (Loop 2310C) 
• Copy REFERRAL to NM104 (Loop 2310C) 
• NM102 = 2 
• Nm103 = SELFREFERRAL
  
  Sample: NM1*73*2*SELFREFERRAL****XX*1002233777~

NDC codes should be reported in Loop 2410 for both X12N Professional and Institutional claims and encounters. The following three segments should be used in Loop 2410: LIN, CTP, and REF. 

1. LIN (Drug Identification) Segment usage
   LIN02 = N4 qualifier for NDC Drug Code
   LIN03 = NDC code in 5-4-2 format.
   Sample: LIN**N4*01234567891~
   
   Please see page 71 of the X12N Professional Addenda (004010X098A1) and page 35 of the X12 Institutional Addenda (004010X096A1) for additional usage information. 
    
2. CTP (Drug Pricing) Segment usage
   CTP04 = Quantity
   CTP05-1 = Unit of Measurement Code values (see below for available list)
    -  F2 International Unit
    -  GR Gram
    -  ML Milliliter
    -  UN Unit
   Sample: CTP****2*UN~
   
   Please see page 74 of the X12N Professional Addenda (004010X098A1) and page 38 of the X12 Institutional Addenda (004010X096A1) for additional usage information. 
    
3. REF (Prescription Number) Segment usage
   REF01 = XZ qualifier for Prescription Number
   REF02 = Prescription Number
   Sample: REF*XZ*123456~
   
   Please see page 77 of the X12N Professional Addenda (004010X098A1) and page 40 of the X12 Institutional Addenda (004010X096A1) for additional usage information. 
   
   Sample of complete NDC reporting:
    -  LIN**N4*01234567891~
    -  CTP***1.15*2*UN~
    -  REF*XZ*123456~

For both institutional and professional EDI claims report Prior Authorization Number in REF02 segment in Loop 2300. Use the "G1" qualifier in the REF01 segment of Loop 2300. 

REF01 = G1 
REF02 = Authorization Number 
Sample: REF*G1*12456789ABCD

Report the entity that approved the authorization (BSC, IPA, NIA), authorization date, date range of the service approved, and approved days/units in NTE02 Loop 2300. For professional claims use Claim Note, and for institutional claims use Billing Note. In both Professional and Institutional claims, use "ADD" as the value in NTE01.

For example: 

• First field: BSC, IPA, or NIA 
• Second field: Provide date the authorization was given (use ccyymmdd format) 
• Third field: Provide date range approved (use ccyymmdd ccyymmdd format) 
• Fourth field: Provide either the amount of days or units approved 
  Sample: NTE*ADD* BSC 20050719 20050719 20050722 4 DAYS

Yes, Blue Shield of California accepts Coordination of Benefits (COB) claims for professional and institutional claims. The following guides provide specific information necessary to correctly adjudicate and process the claims accurately. 

837 Institutional secondary tertiary claims (PDF 72 KB)

837 Professional secondary tertiary claims (PDF 72 KB)

837 Dental secondary tertiary claims (PDF 151 KB)

Per CMS rules, ICD-10-CM procedure codes were named as the HIPAA standard code set for inpatient hospital procedures. The ICD-10-CM procedure codes were not named a HIPAA standard for procedures in other settings such as hospital outpatient services or other types of ambulatory services. Hospitals may capture the ICD-10-CM procedure codes for internally tracking or monitoring hospital outpatient services, but when conducting standard transactions, hospitals must use HCPCS codes to report outpatient services at the service-line level and the claim level, if the situation applies. Even though an ICD-10-CM procedure code qualifier is available in addition to a HCPCS code qualifier at the "situational" claim level segment, the Transactions and Code Sets regulation states that ICD-10-CM procedure codes are the adopted standard code set for hospital inpatient services. 

If Blue Shield of California receives the ICD-10-CM procedure code on an outpatient claim, the claim will be rejected with the following HIPAA rejection code on Blue Shield of California's Submitter Report: 

H51087 According to the HIPAA Regulation, ICD-10 Procedure Codes should only be used on inpatient claims

PER CMS Guidelines, Blue Shield of California is currently accepting Electronic Claims. Using the 837I, submit the POA indicator in segment K3 in the 2300 loop, data element K301.

Refer to the following tables for more information: 

POA:  "POA" is always required first, followed by a single indicator for every diagnosis reported on the claim. 

Y:  The principal diagnosis is always the first indicator after "POA." In this example, the principal diagnosis was present on admission. 

N:  The first secondary diagnosis was not present on admission, designated by "N." 

U:  It was unknown if the second secondary diagnosis was present on admission, designated by "U." 

W:  It is clinically undetermined if the third secondary diagnosis was present on admission, designated by "W." 

1:  The fourth secondary diagnosis was exempt from reporting for POA, designated by "1." 
Sample 1: POA indicators for an electronic claim with one principal and five secondary diagnoses should be coded as POAYNUW1YZ
Sample 2: POA Indicator for an electronic claim with one principal diagnosis without any secondary diagnosis should be coded as POAYZ

POA:  "POA" is always required first, followed by a single indicator for every diagnosis reported on the claim. 

Y:  The principal diagnosis is always the first indicator after "POA." In this example, the principal diagnosis was present on admission. 

Z:  The letter "Z" is used to indicate the end of the data element. 
Current inbound samples:

   K3*POANYZ~ 
   K3*POAYYYYYYYYY1Z~ 
   K3*POAYYYNYYYYYYYYYYYYYY111111Z~ 

ERA/EFT frequently asked questions
ERA is an electronic transaction that enables providers to receive claims payment information electronically. Files are transmitted in the HIPAA-mandated ASC X12 835 4010 A1 format.

In addition to receiving electronic files, new ERA subscribers continue to receive paper EOBs and checks for 45 days following enrollment. This transition period allows you to reconcile one full payment cycle before you transition to all electronic files. Data received during the transition period is live data, so it will match the paper EOBs. During this period, you should test your posting software to ensure proper set-up. You will be notified of the specific date we will stop mailing your paper EOBs. 

There is a 10-day period required after enrollment in EFT to verify bank account information, and allow a smooth transition from paper checks to EFT. You will be contacted via e-mail, phone, or fax to notify you that your EFT enrollment is complete. 

Provider Connection account managers can view payment preferences online from their account management page. Click “Update your provider’s information” under Provider and Practitioner Profiles, then click the Remittance and Payments tab.

Providers may choose to receive their ERA directly from Blue Shield of California / Blue Shield of California Promise Health Plan at no cost via Secure File Transfer Protocol (SFTP). 

Providers who currently use a clearinghouse for electronic claims submission may continue to receive their ERA through their current clearinghouse. Contact your clearinghouse directly to enroll in ERA. 

Use the claims payment search option to generate a summary report of all claims associated with a check or EFT. EOBs issued within the past 24 months are available to print or download. Search online using the claim or payment information to link to the EOB report. 

EFT is issued within two business days of the provider's receipt of the ERA file. 

Our overpayment recovery does not change once you enroll in EFT. We will only reverse an EFT deposit from your account if it is a duplicate or erroneous EFT. 

The automated clearinghouse number found in the EFT addenda record links the EFT and ERA together. This trace number may be considered the check number for comparison. You must work with your bank if you wish to be notified when EFTs are credited to your account.

Assistance with electronic remittance advice or electronic payments is available through the EDI Help Desk. Contact the Help Desk at:

 Phone: (800) 480-1221

Providers receiving ERAs may obtain a copy of their EOB in their Provider Connection account, through the Check Claim Status feature.