CMS 1500 - Professional Claim form guidelines and procedures
UB-04 - Institutional claim form guidelines and procedures

CMS 1500 - Professional Claim form special billing guidelines and procedures

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, submit an EDI inquiry or 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.

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

CMS 1500 completion instructions

The following instructions generally apply to the indicated "Block" on the CMS 1500 claim form.

Block 1 - 8: Patient information

1a. Insured's ID number
Enter the insured subscriber's ID number exactly as it is shown on the Blue Shield Identification (ID) card.

Always include the 3-character prefix that precedes the identification number on the patient or subscriber's ID card. This will ensure proper eligibility identification of the patient and enable Blue Shield to route out-of-state subscriber claims to the appropriate Blue Cross/Blue Shield Plan.

Blocks 9 - 9d: If Blue Shield is the Secondary Payer

In addition to the information in blocks 9 - 9d, the following primary insurance information is required for paper claims:

  • Amount Allowed
  • Amount Applied to Deductible, and/ or
  • Amount Paid.

Blue Shield can accept claims when Blue Shield is the secondary payer. Consult your software documentation or vendor to determine if your software package can support submitting secondary insurance claims.

Block 10a - 10c: Patient Condition

Auto or Other Accident (injury) indicator must be contained in the correct field for the Date of Injury.

Block 14: Date of Current Illness, Injury or Pregnancy

Date of illness, injury or pregnancy is always a required field for Auto or Other Accident.

Block 17 - 17b: Referring or Ordering Physician

17. Name of Referring or Ordering Physician or Other Source
Enter as last name, first name.

Note: Physicians rendering services to a Blue Shield POS member who has self-referred must enter the words "self-referral" in this Block for Blue Shield to accurately identify and process the claim under the PPO benefit plan coverage.

17b. National Provider Identifier (NPI) Number of Referring/Ordering Physician
When possible, enter in this block the NPI of the referring physician. If the NPI is not known, please leave this field blank.

Block 21: Diagnosis. Sign and Symptom

Enter the diagnosis/condition of the patient by using a current ICD-10-CM code number. Enter up to four 5-digit codes in priority order. The primary diagnosis code must be in the #1 position of block 21. The secondary diagnosis code must be in the #2 position of block 21. If more than four codes are listed on a requisition, submit no more than the top four codes.

Do not:

  1. Use verbal descriptions instead of codes.
  2. Truncate ICD-10-CM codes: all codes must be used at their highest level of specificity (assign the fourth or fifth digit sub. classification where it exists to ensure accurate processing)
  3. Code in the decimal point

Blocks 24a - 24j: Detail of Services. Items Rendered

24a. Dates of Service
Enter the month, day and year for each procedure, using the format "MMDDYY." Report all services provided on the same day for the same patient using only one claim form to ensure correct benefit coverage. Date spans on a single line should not cross months. Date spans on a single claim should not cross years.

24d. Procedure, Service or Supply
Enter the procedure, service or supply using the most recently published AMA Current Procedural Terminology (CPT) code or HCFA Common Procedure Coding System (HCPCS). When applicable, also enter the CPT or HCPCS modifiers. Block 24d contains space for up to four modifiers. When more than four modifiers apply, enter the modifier 99 (for multiple modifiers), and then use the "Comments" field (Block 19) to explain the modifiers. When an unlisted procedure is billed, (e. g. 43499), a description of the actual service must be provided in block 19, or the operative report (or radiology, etc.) must be submitted.

Report anesthesia services using the five-digit American Society of Anesthesiologists (ASA) coding system, plus the status modifier code (PI through P6). Also submit Anesthesia time in minutes, standard time in box 24g. Separately report special circumstances that may warrant an additional charge using code 99100 through 99140.

24i. Qualifier for Performing/Rendering Physician or Provider PIN and National Provider Identifier (NPI)
Use the shaded area to enter the appropriate qualifier for the non-NPI reported in the shaded area of 24j.

24j. Performing/Rendering Physician
Enter the rendering provider or supplier taxonomy code in the shaded area of 24j. Enter the rendering provider or supplier NPI in the non-shaded area of 24j.Provider organizations such as medical group practices or clinics must include the rendering provider taxonomy code and the NPI of the performing provider on all claims. Providers who bill as individual practitioners should also include on their claims their taxonomy code and the NPI if they actually performed the service. Do not use the taxonomy or NPI of the supervising physician.

Note: Claims from group practices submitted without the performing or rendering taxonomy code in Block 24j will be rejected.

Blocks 25 - 33: Physician or Supplier Billing Information

25. Federal Tax ID Number, EIN or SSN
Enter the provider/supplier Federal Tax ID, Employer Identification Number or Social Security Number as it is shown on Blue Shield's Provider File for the PIN assigned to the physician/supplier of services.

31. Signature of Physician or Supplier Including Degrees or Credentials
Enter as last name, first name of treating physician.

32. Service Facility Location Information
Enter as the name and address of the location where services were rendered.

32a. Service Facility Location PIN
When possible, enter the service facility PIN.

32b. Service Facility Location National Provider Identifier (NPI)
When possible, enter the service facility NPI.

33. Provider's/Supplier's Billing Name, Address, Zip Code, and Phone Number
Enter the name, address and telephone number given to you by the Provider Relations Liaison Department to identify the practice location from which the claim is submitted.

For individual provider or supplier billing, enter the Blue Shield individual PIN in box 33b.

For physician medical group practice or clinic billing, enter the Blue Shield group PIN in box 33b. A medical group practice or clinic must also enter the PIN of the performing provider in block 24j.

Note: Claims from group practices submitted without the performing or rendering PIN in Block 24j will be rejected.

33a. Provider's/Supplier's Billing Name National Provider Identifier (NPI)
Enter the billing provider / supplier's NPI.

33b. Provider's/Supplier's Billing Name PIN
Enter the PIN given to you by the Provider Relations Liaison Department to identify the practice location from which the claim is submitted.

Additional claims submission pointers

Electronic claim tips (PDF, 59 KB)

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.

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

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: Blue Shield and Blue Shield Promise do require that all claims be submitted 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.

Download UB-04 - Institutional Claim form (PDF, 216 KB)

UB-04 completion instructions

Each field on the UB 04 (or successor) form is called a "form locator." The following form locators merit special attention:

Provider Name and address (Form Locator 1)
Submit the Provider Name, Address line 1, Address line 2, Provider City, Provider State and Provider Zip Code.

Type of Bill (Form Locator 4)
Submit the type of bill.

Tax ID (Form Locator 5)
Submit the Federal Tax ID of the facility.

Statement Covers Period (Form Locator 6)
Enter dates of service that correspond to the charges. Do not enter billing or posting dates.

Name on Baby's Claim (Form Locator 8a)
When submitting a separate claim for a level two , three or four NICU newborn, enter the baby's name rather than "baby boy" or "baby girl." In the case of twins, indicate the baby's name rather than "Baby A" or "Baby B." Blue Shield will return the unprocessed claim if the baby's name is missing. To find information on additional family members, visit blueshieldca.com/provider and link to eligibility from the claim information.

Patients Address (Form Locator 9a-d)
Submit the Patient's address, city, state and zip code.

Patient Date of Birth (Form Locator 10)
Submit the Patient's date of birth.

Sex of Patient (Form Locator 11)
Submit the sex of the patient.

Admission Date (Form Locator 12)
Submit the date the patient was admitted, this includes outpatient claims.

Type of Admission (Form Locator 14)
Submit the Type of Admission.

Source of Admission (Form Locator 15)
Submit the Source of Admission.

Maternity Claims
Charges for the mother and level one NICU baby should be billed together. However, if the baby requires placement in a level two, three, or four Neonatal Intensive Care Unit (NICU) room (revenue code 172, 173 or 174, respectively), separate claims should be submitted for the mother and baby.

Note: For network hospitals with negotiated per diem/case rates, only one per diem/case rate will be paid for both the mother and baby, except when the baby requires placement in level two, three or four NICU or if the baby is in a level one NICU after the mother's discharge.

Late Discharge (Form Locator 16)
Only medical necessity justifies an additional half-day or full-day charge on the day of discharge. Documentation of medical necessity must be attached to the claim form.

Subscriber Information (Form Locator 38)
Submit the Subscriber's name, address, city, state and zip code. Do NOT enter Blue Cross or Blue Shield POB 1505, Red Bluff, CA address. The Subscriber address should be submitted in this field.

Covered Days (Form Locator 39-41)
Submit the number of Non-Covered Days as a value code (qualifier 81).

Non Covered Days (Form Locator 39-41)
Submit the number of Covered Days as a value code (qualifier 80).

Coinsurance Days (Form Locator 39-41)
Submit the number of Coinsurance Days as a value code (qualifier 82).

Lifetime Reserve Days (Form Locator 39-41)
Submit the number of Lifetime Reserve Days as a value code (qualifier 83).

Revenue Codes (Form Locator 42)
Submit the Revenue Code for the services provided.

HCPCS Codes (From Locator 44)
Submit the HCPCS and appropriate modifier, rate or HIPPS code for the services provided.

Service Date (Form Locator 45)
When billing for outpatient services and the "Statement Covers Period" (Form Locator 6) spans multiple dates, each service must be entered on a separate line with the actual date of service performed.

Multiple room and board individual dates of service are needed to process inpatient claims within form locator 45 or on the itemization.

Note: For network hospitals with negotiated per diems, additional payment for late discharges cannot be made under the terms of your contract.

Outpatient Charges and Multiple Inpatient Room & Board Charges
must identify the date on each service line.

Number of Services Performed (Form Locator 46)
Submit the Number of Services provided for each revenue code.

Billed Charges (Form Locator 47)
Submit the Billed Charges for the service performed.

National Provider Identifier - NPI (Form Locator 56)
Enter the Billing Provider NPI number.

Other PRV ID (Form Locator 57)
Enter the Blue Shield of California and Blue Shield Promise Provider Identification Number (PIN), including the alpha prefix and suffix (e.g., ZZZC0406Z).

Coordination of Benefits (Form Locator 58-65)
When more than one insurance carrier is involved, enter complete information regarding the primary, secondary, and other carriers and members. Indicate the other insurance carrier's name, address and policy number in the "Remarks" section. Also include any payment information, if known. When Blue Shield is the secondary payer, attach a copy of the primary carrier's remittance advice or EOB. Also attach a copy of the other insurer's identification card, if available.

If other insurance is indicated:

  • Line A - Enter the Primary Carrier information.
  • Line B - Enter the Secondary Carrier information.
  • Line C - Enter the Tertiary information.

Pre-admission Number (Form Locator 63)
Enter the reference number that Blue Shield issues to track pre-admission information. For Access+ HMO and POS patients, enter both the Blue Shield tracking number and the reference number provided by the patient's IPA/medical group, if applicable. For emergency room visits, enter the name or license number of the authorizing physician, if the patient's Primary Care Physician referred or approved the admission.

Diagnosis (Form Locator 67 A-Q)
Enter all the diagnosis codes, using the current ICD-10-CM Manual, for accurate coding. All diagnoses must be coded to the highest level of specificity. The final diagnosis must appear on all claims. The admitting diagnosis is sufficient on interim claims. If no diagnosis is indicated, Blue Shield will be unable to process the claims; if no diagnosis is indicated on an electronic claim, it will be rejected.

DRG Code (Form Locator 71)
Enter the appropriate DRG code.

Principal Procedure / Other Procedure (Form Locator 74 a-e)
ICD-10-CM procedure codes are the standard code set for inpatient hospital procedures. Hospitals may capture the ICD-10-CM procedure codes for internally tracking or monitoring hospital outpatient services; but when submitting claims hospitals must use HCPCS codes, and appropriate modifier, to report outpatient services at the service line level and the claim level, if the situation applies.

Electronic claim Principal Procedure:

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.

Attending Physician (Form Locator 76)
Enter the name, provider ID number (PIN) and NPI of the attending physician.

Operating Physician (Form Locator 77)
Enter the name, provider ID number (PIN) and NPI of the operating physician.

Other Physician (Form Locator 79)
Note: Facilities rendering services to a Blue Shield POS member who has self-referred must enter the words "self-referral" in this form locator for Blue Shield to accurately identify and process the claim under the PPO benefit plan coverage.

Electronic claim record of Referring Physician:

  • Last Name Field (Claim Header Record) - Enter "Self-referral"
  • First Name Field (Claim Header Record) - Leave Blank

Taxonomy Code (Form Locator 81)
Enter the taxonomy code with qualifier "B3".

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 (as described in Appendix J-2), 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 65 Plus claims, the rendering physician's state license or UPIN must be entered in this field.