Provider Connection Reference Guide Form

Provider Connection Reference Guide The Provider Connection website gives you easy access to the tools and information you need to serve Blue Shield and Blue Shield Promise members as well as to support your practice. Use this reference guide to learn more. 12/10/2025

Blue Shield of California | Blue Shield of California Promise Health Plan 2 Blue Shield/Blue Shield Promise Provider Connection reference guide directory Page Action 3 Registration & account management for Account Managers and Users 4 Website navigation 5 Provider directory online validation and update process • Assign user access to provider demographic information 7 Verify member eligibility plus view eligibility and coverage details, benefits, and member’s ID card 13 Create member rosters 14 Locate authorization tools and resources 15 Options for submitting claims 16 Use the Claims routing tool to determine where to send paper claims 17 Account Managers: Enroll in ERA and EFT online plus check or edit enrollment status 18 Use Check claim status to search claims and find EOBs 20 Attach documentation to a finalized claim 21 Submit a dispute online or by mail 22 Use View my disputes to track disputes and access determination letters 24 Quick links If you are viewing this guide online, the linked page numbers take you to instructions for key activities you can do on Provider Connection . Use the Directory button at the bottom of each page to return to this table of contents.

Blue Shield of California | Blue Shield of California Promise Health Plan 3 Establishing a Provider Connection account as an Account Manager or User Establishing an account: The person executing the initial Provider Connection registration is considered an Account Manager. When the maximum allowed number of Account Managers register, Provider Connection will display a message. Most organizations can have at least two Account Managers. There are three types of provider accounts. The links below take you to step

• by - step instructions with screenshots for how to register for the account type most appropriate to your business. 1. Provider 2. MSO 3. Billing Service Account Managers: Once registered, the Account Manager(s) will see an Account management link in their top - level navigation after log in. It provides direct access to all activities falling within the role. Once established, the Account Manager(s) – not Blue Shield – sets up user profiles. Blue Shield will email each user a link to f inish establishing their account. Users have 30 days to visit the site and complete this process. If a User does not do so within 3 0 d ays, the Account Manager will need to recreate their profile. Users: All users (and Account Managers) have a Manage my profile page where they can do things like update their username/ password, change their email, set their email preferences, and locate their Account Manager. After log in, a “badge” with the

  user’s initials appears at the end of the white navigation bar. Click this badge to access the Manage my profile page. Additional support: • This Provider Connection Account FAQ provides answers to the most frequently asked questions about establishing and maintaining a Provider Connection account as an Account Manager or user. • A password must be updated every 365 days. See Update your Provider Connection password if you need help changing your password or if your account is locked or disabled. • The Provider Connection training page includes links to the above resources and more. No log in is required. Background: If your organization is new to Provider Connection , you must establish an account. Directory

Blue Shield of California | Blue Shield of California Promise Health Plan 4 Instructions: 1. Top level navigation: Log in/Register and general site actions such as Contact us and Help . • Blue Shield uses two

• step authentication. To verify your identity each time you login, enter your username/password plus the code Blue Shield sends to your email. • After logging in, you will see an “Account” dropdown menu. Click to access the M y profile , Message center, and Account management pages. 2. Main navigation bar: Links to the five main site sections, and Search. When you click a section link, the blue line indicates the section drop - down menu you have activated. 3. Section drop -down menu: Links to the most
• used content and tools within the specific section. 4. Overviews: Each section has an overview that provides a high
• level table of contents for information on the page. Provider Connection website navigation Background: Below is a high
• level snapshot of how to navigate the Provider Connection website. Authenticated tools require log in, but there are many resources on Provider Connection that do not. Directory 3 Tip: Blue Shield Promise resources that do not require log in are integrated throughout Provider Connection. They are also available from the Blue Shield Promise Provider Portal . Links in the footer of each website allow you to move between the two websites. 4 1 2 3

Blue Shield of California | Blue Shield of California Promise Health Plan 5 Process: • Online attestation to data accuracy every 90 days, even if data has not changed. Blue Shield will alert a provider when it is time to attest. • Directory updates at any time either by: ▪Single edits on the Provider Connection Provider & Practioner Profiles page. ▪Blue Shield’s bulk data file – the Provider Data Validation Spreadsheet – downloaded from Provider & Practioner Profiles, then uploaded back to the page. Visit the Provider data management section for these resources : 1)How to attest and update your provider directory information ( the full process), 2) Provider Data Validation User Guide (detailed instructions on how to make demographic updates in the bulk data file/spreadsheet.), and 3) Updating your Provider and Practitioner provides eLearning (overview and step -by-step explanation of the bulk data file process) Who can execute this process: • Provider Connection Provider and MSO Account Managers and users to which they give provider demographic information access. See instructions on the next page for how to assign user access. ▪Billing Managers have view

• only access. High -level provider directory validation process Background: Blue Shield has designed our provider directory accuracy processes to be compliant with both the 2021 Consolidated Appropriations Act (CAA) and California Senate Bill (SB) 137 requirements. Directory

Blue Shield of California | Blue Shield of California Promise Health Plan 6 Background: Account Managers can assign provider demographic data access to designated users so that the most appropriate staff members validate/update/attest to provider directory information. Instructions:

1. From the Account management page, select Manage your user accounts located under the Manage user accounts section.
2. Select the View link for a specific user.
3. That user’s Account information displays.
4. Move the Provider & practitioner data toggle to Yes (the right).
5. Scroll down and select Save . Account Manager assign user access to provider & practitioner demographic information Directory 2 4 3

Blue Shield of California | Blue Shield of California Promise Health Plan 7 Verify member eligibility Background: Verify eligibility lets you confirm that a patient is a Blue Shield, Blue Shield Promise or Other Blue Plan member. The tool contains up to two years of data at any one time. It is updated daily.

3. Verify eligibility opens and defaults to SEARCH SINGLE MEMBER . Click SEARCH MULTPLE MEMBERS to search for up to 10 subscriber IDs at one time.
4. For single member search, enter member data using one of the following: • Subscriber ID (9
   • 16 alpha numeric characters) • Member name and date of birth • Last four (4) digits of SSN • MBI and date of birth (Medicare only) • First nine (9) characters of CIN
5. Click the active Search button. The eligibility results screen displays – see next page . Instructions:
6. After log in, click Verify eligibility from the home page or click Eligibility & benefits from the white navigation bar.
7. Click Verify eligibility from the drop - down menu. 4 5 4 3 5 1 2

Blue Shield of California | Blue Shield of California Promise Health Plan 8 1. Status: Eligibility is green if active. 2. Upper right navigation provides links to eligibility details, a PDF of the member ID card, benefits, and Check claims status . 3. When Blue Shield is not primary, Coordination of Benefits (COB) information will display for members if the data is in our system. Note: When verifying eligibility for Blue Shield TotalDual (HMO D

• SNP) members with matching Medi - Cal through Blue Shield Promise (“full duals”), two of the above results panels will present, one for Medicare (primary) and one for Medi
• Cal (secondary). When this is the case, the member ID card will be active on the Medicare results screen and inactive on the Medi
• Cal. Verify member eligibility continued MEMBER, G 2 1 3 Directory

Blue Shield of California | Blue Shield of California Promise Health Plan 9 For the following six networks, the eligibility results screen tells you if you are in or out of the member’s network: 1. PPO DMHC 2. PPO DOI Blue Shield Life 3. IFP EPPO 4. CalPers EPO 5. PPO GMAPD 6. PPO IMAPD If you have one Tax ID/SSN and one Blue Shield Provider ID (PIN), Network status will automatically populate with either in

• or out - of- network status. Background: Clicking Details from the eligibility results screen provides access to additional information about the member. The first item you will see is Network status . 4343001 -- PALOMAR CITY MED CTR MEMBER, A MEMBER, A 4343001 -- PALOMAR CITY MED CTR Member eligibility details – Member network status If you have more than one TIN registered with Blue Shield or multiple PINs, you will see a Check status link in the Network status section. Click that link to launch a network status search. See instructions on the next page.

Blue Shield of California | Blue Shield of California Promise Health Plan 10 If you have more than one TIN registered with Blue Shield and/or multiple PINs, Provider Connection will ask you to search for network status. Based on your TIN/PIN configuration, it will ask you to complete one or more popups: • Identify the appropriate Tax ID by selecting or searching in the pop - up. Click Continue . • Select from a list if you have between 1 - 5 Tax IDs • Enter search criteria if you have 6+ Tax IDs • Identify the appropriate provider by selecting or searching in the pop

• up. Click Continue . • Select from a list if there are 2 - 5 providers • Enter search criteria if there are 6+ providers 10 4 • If the location you select IS NOT in one of the networks, you will see an Out of network indicator. Click Back to select a different location if appropriate. Click Close to return to the Details page. • If the location you select IS in one of the networks, you will see an In network indicator. Click Close to return to the Details page. • Network status – either in or out – will display on the Details page with the location you selected. • For members not in one of the networks listed on the previous page, providers will be directed to Find a Doctor to determine network status. • For capitated members, providers will be directed to contact the IPA. Member eligibility details – Member network status continued Directory

Blue Shield of California | Blue Shield of California Promise Health Plan 11 Background: Clicking Details from the eligibility results screen provides access to additional information about the member. After Network Status, the following information displays. 11 1. General member information 2. Special programs eligibility Click the + sign to expand these sections as needed: 3. Member coverage information including COB if applicable and in our system. 4. Total deductibles, copays, and out

• of- pocket maximums. 5. PCP and IPA/medical group assignment if applicable. View member eligibility details – Coverage, deductibles, PCP assignment 555-555-5555 1 2 3 4 5 Tip: The Visits Accumulator presents as part of Deductibles/OOP for Commercial members only. It tracks visits to specialty providers when their plan covers a set number of visits per plan year. Specialty visits covered by third parties such as American Specialty Health (ASH) are not tracked by the tool. Background: Clicking Details from the eligibility results screen provides access to additional information about the member. After Network status , the following information displays. Directory

Blue Shield of California | Blue Shield of California Promise Health Plan 12 1. Benefit summary view is the default – lists benefits in alpha order on the left with details on the right. 2. Benefit categories view expands/collapses on the left with details on the right. 3. The Search field activates when Benefit categories view is clicked. • Benefits are not listed by ICD - 10 codes. 4. Benefits download (if logged in) or go to Benefit summaries if not logged in, to download/view a spreadsheet with detailed benefits for the all plans. 1 2 3 4 View member benefits – Commercial, Medicare, Small Group & IFP Tip: If a Promise Health Plan member, the link from the check eligibility results will take you to the Medi

• Cal Member Handbook EOC. Background: Clicking Benefits from the eligibility results screen provides access to a detailed view of the member’s benefits. Directory

Blue Shield of California | Blue Shield of California Promise Health Plan 13 Instructions: 1. After log in, click Eligibility & benefits from the white navigation bar. 2. Click Member rosters from the drop - down menu. 3. The member updates column displays either New or Updates
(member disenrolled, moved to another PCP, or status changed to redetermined). 4. Click the linked number to view and/or export data. 5. Click Export to download an Excel spreadsheet with full member details. ▪Disenrolled Members Roster includes disenrollment dates. ▪Redetermined Members Roster displays members with upcoming redetermination dates within the next 90 days. ▪On Hold Members Roster displays members who missed their redetermination date and are within the 90

• day grace period. 6. Use Search or click Filter to view/download by provider name, address, PIN or IPA/medical group. Create member rosters Background: Member rosters are lists of Blue Shield and Blue Shield Promise members who have selected a provider as their PCP or medical group. This list shows all providers associated with your account by Provider ID (PIN). Directory JOE J DOCTOR 1 MAIN ST. BREA, CA 90001 1000000002 3 DOCTOR J 1000000002 4 5 6 2

Blue Shield of California | Blue Shield of California Promise Health Plan 14 Locate authorization tools and resources in the Authorizations section Orientation:

1. The overview section provides a high
   • level table of contents for information on the page plus an Authorization basics page that describes the process at Blue Shield.
2. The Authorizations section houses the AuthAccel online authorization tool, available after log in. • Click Medical authorization to submit medical requests via AuthAccel. Click Medical authorization status to view medical request status via AuthAccel, regardless of how they were submitted. ▪AuthAccel instructions are linked to each launch page as well as to AuthAccel Online Authorization System Training . 3. Click Policies and guidelines to search medical and medication policies and requirements. No log in required. 4. Click prior Authorization forms and lists , and to learn about services requiring third
   • party authorization (e.g., National Imaging Associates [NIA]). No log in required. Background: Medical authorizations can be submitted online or fax. Rx requests can be submitted online, by fax, or via the Surescripts® or CoverMyMeds® EHR platforms. Authorization status for all requests can be viewed online via AuthAccel. See Authorization basics for providers for an overview of the authorization process at Blue Shield/Blue Shield Promise. Directory 4 2 2 3 1

Blue Shield of California | Blue Shield of California Promise Health Plan 15 Background: Blue Shield accepts both paper and electronic claims. Paper claims can be sent either by mail or digitally. For additional information, see How to submit claims on Provider Connection – no login required. Options for submitting claims Claims Routing Tool See next page for instru ctions user guide Step 1: Choose an approved EDI clearinghouse page 17 EDI, ERA/EFT and Secondary 277CA FAQ EDI, ERA/EFT and Secondary 277CA FAQ EDI, ERA/EFT and Secondary 277CA FAQ (Paper) Mail • The Claims Routing Tool

tells you where to submit paper claims. No log in is required. • See next page for instructions . (Paper) Digitally •Via SympliSend after logging in to Provider Connection. •To launch, go to Claims > Claim Overview > Submitting .> click the SympliSend link. •See user guide for instructions. Electronically (EDI) • Step 1: Choose an approved EDI clearinghouse . • Step 2: Enroll in ERA and EFT. Provider Connection Account Mangers can enroll online: See page 17 for instructions. • Step 3: Contact the selected clearinghouse to enroll and begin exchanging electronic transactions. • See the EDI, ERA/EFT and Secondary 277CA FAQ . Tip: Via SympliSend, in addition to submitting digital paper claims, you can also submit itemization requests, and digital correspondence related to previously processed or in process claims. Directory

Blue Shield of California | Blue Shield of California Promise Health Plan 16 Use the Claims routing tool to determine where to send paper claims Background: The Claims routing tool tells you where to submit paper claims for Blue Shield/Blue Shield Promise. It can also be used to determine where to send BlueCard claims for out

• of- state Blue plan members. No log in is required to use this tool. Instructions:
  1. No log in is required to use this tool, which is in the Claims section on Provider Connection under Claims Tools .
  2. Click Claims routing tool .
  3. Answer the service provider question.
  4. Enter the first three characters of the member’s ID .
  5. Enter the date of service and click Search . • If requested, enter the rest of the member ID and click Search.
  6. The “send to” address will display. In most cases, so will a phone number for customer service should you need assistance.
  7. Click Start over to conduct a new search. Directory a 6 4 3 5

Blue Shield of California | Blue Shield of California Promise Health Plan 17 Instructions : After log in, Provider Connection Account Managers can determine if your organization is enrolled in ERA/EFT. If yes, you can ed it your selections. If not, you can enroll right from this screen.

1. Click Account Management > Provider & practitioner profiles .
2. If you have more than one Tax ID (TIN), select the correct TIN from the drop
   • down menu and click Search to refresh the screen.
3. Click the Remittance & Payments tab. The screen will open on the EFT information for that TIN. Click Edit to enroll or to change your enrollment information.
4. To view/edit ERA , click ERA in the left navigation. Use the drop
   • down menu to choose a vendor (i.e., clearinghouse or trading partner). The vendor you choose applies to all providers under the selected Tax ID. Changes take up to three (3) business day s. Enroll in ERA and EFT online – Account Managers only Background: Using EDI, you can receive claims payment information electronically (electronic remittance advice or ERA) and you can have claims payments deposited directly into your business account (electronic funds transfer or EFT). Directory JM MEDICAL GROUP JM MEDICAL GROUP Select vendor OFFCE ALLY 3 4

Blue Shield of California | Blue Shield of California Promise Health Plan 18 Check claim status – Search claims and find EOBs Background: Check claim status is available from the home page and from the Claims section after log in. It contains a Search and Other Blue plans tabs. The Appeal status tab links to Submitted disputes on the Claim issues & disputes page. Instructions: You must be linked to the Tax ID and Provider ID (TIN/PIN) of the claim for which you are searching. 1. Click Check claim status. The Search tab displays with claims from the last five years. The most recent will be at the top. 2. Enter data into one or more search fields and click Search. 3. Results will display below the blue header row. To sort results in alphabetical or ascending/descending order, click the desired column header and the up/down arrow once it presents. 4. Click the blue text links to see more detailed information about the member or claim or to view/download the EOB. 5. To clear the search and conduct a one, click Start over. Tip: When using the Other Blue plans tab to conduct a search for member claims, all fields are required unless marked optional. Results will be sent to the user’s Message Center. 2 2 3 4 5

Blue Shield of California | Blue Shield of California Promise Health Plan 19 Background: Clicking the claim number from the Check claim status search results opens the Claim detail page and provides access to the information below. You can toggle between summary and full view. Full view includes all the information you see here plus payment details, service and procedure details, claim message, and claim notes. Check claim status – Claim details screen Directory XXXX XXXX XXXX XXXX XXXX XXXX XXXX The “ Possible next steps ” links change based on the claim’s status. The “ Resolve claim issue or dispute ” link is the default option. Additionally, you may find a “ View letters ” link if letters are available, and an “Attach supporting documents ” link to submit documentation for a finalized claim, if requested by Blue Shield.

Blue Shield of California | Blue Shield of California Promise Health Plan 20 Claims – Attach documentation to a finalized claim Background : For all lines of business, click Attach supporting documents when the claim has been denied or not paid in full, and Blue Shield is requesting additional supporting documentation. Directory To start the process:

1. Click Claims then c lick Check claim status in the blue sub - menu bar.
2. Search for the finalized claim. (See Check claim status for instructions.)
3. Click the claim number to open the Claim detail page.
4. The Claim detail displays for that claim. Click Attach supporting documents . 4
5. The Attach Documents to a Claim screen displays with prepopulated claims data.
6. See the Attach documentation to a finalized claim tutorial for the remaining steps, with screenshots, for how to complete this process. Tip: * Do not use Attach documents to a finalized claim to file a dispute . If you do so, Blue Shield must void your submission, and you will need to resubmit correctly.

Blue Shield of California | Blue Shield of California Promise Health Plan 21 Disputes can be filed for a single claim or multiple claims in a bulk dispute for the same type of issue. To begin the online dispute process, log in and click Claims from the white navigation bar.

1. Click Check claim status in from the drop
   • down menu.
2. Search for the finalized claim. (See Check claim status for instructions.)
3. Click the claim number to open the Claim detail page.
4. Click the Resolve claim issue or dispute link. This link will be active only if the claim has been finalized. • Note, if this is a claim type that cannot be disputed online, the link will say, “file a dispute by mail.”
5. If you know the claim number, you can also file a dispute online directly from Claim issues & disputes, after log in.
6. See the Submit claim disputes online and view status tutorial for the remaining steps, with screenshots, for how to submit an online dispute. Claim issues & disputes – Submit a dispute online Background : Disputes for most plan types can be initiated from the 1) Claim detail screen once the claim has been finalized or from the 2) Claim issues & disputes section, if you know the claim number. They can also be filed by mail . 123456789101 Directory Tips: • Do not use the online dispute functionality to attach documents to a finalized claim . If you do so, Blue Shield must void your submission, and you will need to resubmit correctly. • To insure you file a dispute correctly, see Learn more about the dispute process .

Blue Shield of California | Blue Shield of California Promise Health Plan 22 View my disputes: Search disputes and access determination letters Background: The Submitted disputes link is available from the Claim issues & disputes section after log in. It contains all disputes submitted online or by mail. 1. Click Claim issues & disputes from the Claims section’s drop - down menu after log in. 2. Scroll to the blue box and click View my disputes . 3. Enter data related to the dispute(s) in one or more fields and click Show results . 4. Results display under the light blue header. 5. Click the dispute case number to access dispute case details including letters. 2 3 4 5 1

Blue Shield of California | Blue Shield of California Promise Health Plan 23 View my disputes: Search disputes and access determination letters continue d 6. The Dispute case details screen displays all information and documentation connected to the dispute case number you selected. a. Dispute form and claim list (if bulk submission). b. Claim numbers included in the dispute submission. c. Supporting document uploaded by you with option to add additional documents to an open dispute. d. Correspondence and determination. 6 a 1 b c d Directory

Blue Shield of California | Blue Shield of California Promise Health Plan 24 View Letters: View letters associated with a claim Directory To view letters:

1. From the Claim status page, select the View letters link.
2. From the View letters popup, select the letter .
3. The letter opens as a PDF. View, print, and download as needed. Background: All correspondence from Blue Shield related to the claim is digitally attached, allowing you to conveniently view, download, and print the letters whenever required. 1 2 3

Blue Shield of California | Blue Shield of California Promise Health Plan 25 Quick click guide – direct links to popular areas on Provider Connection For Blue Shield providers Behavioral health resources Benefit summaries BlueCard Program Claims policies & guidelines Clinical policies and guidelines Professional fee schedule search Drug formularies Forms Member ID card samples Patient care resources Provider manuals Richman injectables policy Spine surgery/pain management prior auth and Radiology and imaging prior auth • National Imaging Associates (NIA) RadMD Sign in Background: Blue Shield Promise resources that do not require log in are integrated throughout Provider Connection. They are also available from the Blue Shield Promise Provider Portal . The links below will take you to content on Provider Connection, and in some cases, to content on the Blue Shield Promise Provider Portal . Directory For Blue Shield Promise providers Benefit summaries Behavioral Health Services Clinical policies and procedures Complex Case Management Drug formularies Forms Health education resources Medi - Cal Provider Incentive Program Member ID card samples Patient care resources Provider manuals Quality improvement

• Log in required.

Blue Shield of California and Blue Shield of California Promise Health Plan are independent licensees of the Blue Shield Association