Payment policies and rules

Prescreen claims

Use the Clear Claim Connection (C3) simulation tool to test HCPCS/CPT codes and view clinical edits with rationales.

Payment processing codes

Refer to the following documents for Blue Shield's payment processing logic and procedure codes:

Blue Shield Payment Processing Logic (PDF, 18 KB)

Hospital Acquired Condition (HAC)/Never Events Codes (Excel, 346 KB) Effective 10/01/2022 - 09/30/2023

Incidental Procedure Codes (PDF, 73 KB)

Office-Based Ambulatory Procedure Codes (PDF, 90 KB)

Local Code/National Code Crosswalk (PDF, 146 KB)

Payment policies

Claims resources

How to prescreen claims with C3 (PDF, 540KB)

Intro to Clear Claim Connection - recorded webinar (34 minutes)

Intro to Clear Claim Connection - presentation (PDF, 816 KB)

Clean claims submission tips (PDF, 24 KB)

Ancillary claims filing guidelines

Review claim submission requirements for Blue Shield of California labs, specialty pharmacy and DME providers.

Review guidelines

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.

View guidelines

Enroll in EDI

Learn how to submit all of your claims and receive your payments electronically for faster processing and payment using electronic data interchange (EDI).

Learn more

Professional fee schedule for Blue Shield of California providers

Search the professional fee schedule for Blue Shield of California allowances and learn how we establish them.

Learn more about professional fee schedule

Provider appeals

Get details about the provider appeals including forms for dispute resolution.

Review regulations for Blue Shield of California providers

Review policies for Blue Shield of California Promise Health Plan providers

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.

Find requirements