In response to frequent issues resulting in claim denials, we have compiled the following tips to help you correctly submit Medi-Cal claims to Blue Shield of California Promise Health Plan, in general and for specific procedures, items, and services noted below.
File in a timely manner
| Coordination of Benefits (COB) | Explanation of Benefits (EOB) submitted by providers from other plans for secondary payment consideration must be submitted within 90 days of other insurance carrier’s payment/denial date. |
| Non-contracted providers | Initial claims for services provided to Blue Shield Promise members should be submitted within 180 days of the date of service. |
| Contracted providers | Initial claims for services provided to Promise Health Plan members should be submitted within 180 days of the date of service unless otherwise agreed upon in the Participating Provider Agreement. |
| Corrected Claims | Corrected claims must be submitted within 180 days of the original claim paid date unless otherwise agreed upon in the Participating Provider Agreement. |
Use Medi-Cal surgical modifiers
Blue Shield of California Promise Health plan requires Medi-Cal surgical modifiers for Current Procedural Terminology (CPT) codes 10000-69999 to be included in claims. Claims submitted without the required modifiers will be denied.
Bill with modifiers AG, 50, 51, 99 for professional surgical providers. For assistant surgeons, providers should bill using modifier 80 for applicable surgical codes.
| MODIFIER | DESCRIPTION |
|---|---|
| AG | Primary Surgeons, Multiple Primary Surgeons |
| 50 | Bilateral Procedure |
| 51 | Multiple Procedures |
| 80 | Assistant Surgeon |
| 99 | Multiple Modifiers |
Facility providers should bill for the room charge and/or surgery supplies according to the guidelines below.
- For room charge codes, refer to the Medi-Cal manual
- For surgical supplies billed by a facility, refer to the definitions below for the surgery-related drugs and supply modifiers:
| MODIFIER | DESCRIPTION |
|---|---|
| UA | Used for surgical or non-general anesthesia-related supplies and drugs, including surgical trays and plaster casting supplies, provided in conjunction with a surgical procedure code. |
| UB | Used for surgical or general anesthesia-related supplies and drugs, including surgical trays and plaster casting supplies, provided in conjunction with a surgical procedure code. |
Bill sales tax at the approprate rate
For medical supplies: Items are reimbursable at the current provider county sales tax rate.
For incontinence supplies and durable medical equipment (DME): Items are reimbursable at the current California state sales tax rate.
Enter correct National Drug Codes (NDCs) for physician-administered drugs (PADs)
Per the Medi-Cal manual Physician-Administered Drugs – NDC: CMS-1500 Billing Instructions
(“physician ndc cms”) and Physician-Administered Drugs – NDC: UB-04 Billing Instructions
(“physician ndc ub”), an 11-digit NDC number must be entered on the claim.
- Enter an 11-digit NDC number on the claim as per Medi-Cal manual instructions.
- Ensure the NDC has five digits in the first segment, four digits in the second segment, and two digits in the last segment.
- Bill the product ID qualifier N4 followed by the 11-digit NDC, along with the corresponding unit of measure qualifier (ML, GR, UN) and the numeric quantity (10-digit number).
Absence of these elements will result in claim denial. An incorrect unit of measure qualifier or numeric quantity will also result in claim denial.
Refer to these guides for care facility claims
The following guides are available to help you submit claims for services provided by long-term care (LTC) facilities, intermediate care facilities for developmentally disabled (ICF/DD) members and skilled nursing facilities (SNF).
Billing Guide for LTC Facilities Effective 2/1/24 (PDF, 161 KB)
Billing Guide for ICF/DD Facilities Effective 2/1/24 (PDF, 162 KB)
SNF Claims Billing Guide DOS Prior to 2/1/24 (PDF, 323 KB)
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