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FAQS for EDI, ERA/EFT AND SECONDARY 277CA

This page provides helpful information about electronic claims transactions and how to indicate specific elements on electronic claims.

Find answers to frequently asked questions on the following topics:

  • National Provider Indicator (NPI)
  • Corrected claims
  • Self referral codes
  • National Drug Code (NDC)
  • Prior authorization number
  • ICD-10-CM Procedure Codes
  • Present on Admission (POA) Indicator
  • ERA and EFT
  • Secondary 277CA for adjudicated encounters

Be sure to share this information with your practice management system vendor as you may require updates to your electronic claims billing software.  

Note: ERA is an electronic transaction that enables providers to receive claims payment information electronically. Files are transmitted in the HIPAA-mandated ASC X12 835 format.

  • How do I sign up for Provider electronic payments?

    To allow electronic payments, fill out the Provider Authorization Form (PDF, 101 KB).

  • Do I have to pay a transaction fee for EDI claims submissions?

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

  • Can I use any software vendor when submitting transactions electronically?

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

  • Can I use any Clearinghouse for my connection?

    Only clearinghouses approved by Blue Shield of California (PDF, 106 KB) may be used to connect to Blue Shield of California.

    Blue Shield of California Promise Health Plan providers must use one of these two approved clearinghouses:

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

    Change Healthcare Claims
    Payer ID: 57115
    (866) 371-9066
    www.changehealthcare.com

  • How will I know if it my electronic claim is accepted or rejected?

    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. 

  • What are the most common reasons EDI claims fail to process?

    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
  • Do I need to include the National Provider Indicator (NPI) on my electronic claims?

    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 at their website.

  • How do I submit corrected claims electronically?

    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).

  • How do I indicate "self referral" for point of service (POS) on a professional claim?

    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~ 
  • How do I indicate "self referral" for point of service (POS) on an institutional claim?

    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~
  • How do I report National Drug Codes (NDC) codes on X12N EDI claims and encounters?

    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~
  • How do I report prior authorization numbers?

    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
  • Does Blue Shield of California accept Coordination of Benefits (COB) claims?

    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)

  • Why does Blue Shield of California handle ICD-10-CM Procedure Codes for inpatient claims only?

    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.

  • How do I code the Present on Admission (POA) indicator?

    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. 

  • What is the transition process like from paper EOBs to electronic remittance (ERA)?

    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. 

    If you wish to shorten or extend the transition period, contact the EDI Help Desk. 

  • How long does it take to enroll in EFT?

    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. 

  • How do I know I am signed up for ERA/EFT?

    Providers who are unsure whether they receive ERA or EFT can view their Payment Preferences online from the Account Management link in Provider Connection. Only the registered account manager can access Payment Preferences. 

  • How will I receive my ERA?

    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. 

  • Without a paper EOB, how will I know which claims apply to my check?

    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. 

  • How soon will I receive my EFT payments?

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

  • How do overpayments affect my EFT?

    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. 

  • How can I reconcile my EFT with my ERA?

    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.

  • Whom do I contact if I need assistance with my EFT of ERA file?

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

    Phone:(800) 480-1221
    Email: EDI_BSC@blueshieldca.com

  • Can I continue receiving paper EOBs?

    Providers receiving ERA who are unable to obtain copies of EOBs online must request continuation of paper copies in writing. Please direct correspondence to: 

    Blue Shield of California
          Attn: EDI Exception Processing
          4700 Bechelli Lane
          Redding, CA 96002

    Fax: (530) 351-6150

    Required information includes:

    • Provider name
    • Tax Identification Number (TIN)
    • National Provider Identifier (NPI) number for which paper copies are requested
    • Name, phone number, and e-mail address of a contact person for questions regarding the request
    • An explanation of why continuation of paper EOBs is requested

HIPAA 5010 and ICD-10 implementation

If you conduct business electronically, read about these two significant changes to HIPAA standard transactions and code sets.

Read about the changes in codes

How to enroll in EDI

Follow these easy steps to enroll in EDI for your organization.

Learn how to enroll

EDI Companion Guides

Access our companion guides for trading partners who exchange electronic transactions with us.

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Submit an EDI inquiry

Use this tool to submit your questions about EDI system.

Proceed with the inquiry

Local code crosswalk

Find the national codes that must replace local billing codes.

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Claims and payment forms and templates for Blue Shield Promise providers

Find forms and templates you may need to submit claims and encounters for Blue Shield Promise Medicare, Medi-Cal and Cal MediConnect patients.

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