San Francisco Health Plan Claims Operations Guide for Providers April 2014

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San Francisco Health Plan

Claims Operations

Guide for Providers

April 2014

San Francisco Health Plan 201 Third Street, 7th Floor

San Francisco, CA 94103


San Francisco Health Plan Claims Operations Guide for Providers April 2014









a. Electronic Claims ... 7

b. Checking Claim Status ... 7

c. Corrected Claims ... 7


a. Billing Limits ... 7


a. Other Claim Requirements ... 8








a. Conflicts With Other Common Core Data ... 22

b. Unlisted Services and Procedures ... 22

c. Age Parameters ... 22







a. National Drug Code (NDC): ... 24

b. Unique Product Number (UPN): ... 25



a. Gynecological and OB Services ... 27

b. Anesthesia ... 27





a. Admission Date ... 29

b. Membership Date ... 29

c. Billing ... 29

d. Compensation Conditions ... 29















a. Claims Department ... 36

b. Compliance Department ... 36




Billing for Medi-Cal

San Francisco Health Plan (SFHP) primarily serves Medi-Cal Beneficiaries under a contract with the State of California. SFHP generally follows policies and procedures of the Medi-Cal program. Unless otherwise noted, SFHP’s non-Medi-Cal lines of business also follow Medi-Cal policies and programs. Providers have access to SFHP policies and procedures in this manual. The Medi-Cal program manual may be

found at the ACS (Affiliated Computer Services) manual on

ACS is contracted by the State as the Medi-Cal fiscal Intermediary for the State Medi-Cal program. ACS processes and pays claims for Medi-Cal beneficiaries in Medi-Cal fee-for-service. San Francisco Health Plan is responsible to process and pay claims for its members. If you treat a member who is not a San Francisco Health Plan member, you must bill ACS or the member’s Medi-Cal managed care plan for those services. This rule applies to members whose eligibility is through another county or who have an aid code not covered by San Francisco Health Plan.

San Francisco Health Plan serves Medi-Cal, Healthy Workers, and Healthy Kids lines of business as well as acts as a third party administrator for Healthy San Francisco, a health access program. For more

information on these programs, see the Network Operation Manual on our website,


Authorization Requirements

Any of the services or benefits outlined below are subject to prior authorization requirements. For the most up to date list of prior authorization requirements, please visit our website at or contact us at (415) 547-7818 extension 7080.





This section explains claims submission requirements and

general claims processing information.

1. Claims Contact Information

2. Claims Submission Process

3. Claim Timelines

4. Clean Claims

5. Health Insurance Claim Form (CMS 1500) Instructions

6. Health Insurance Claim Form (UB04) Instructions

7. Other Health Insurance

8. Third Party Liability



Claims Contact Information

San Francisco Health Plan delegates authorization and claim processing to some of its medical groups. SFHP processes claims, in general, for the following medical groups: San Francisco Community Clinic Consortium, San Francisco Health Network (previously known as the Community Health Network) and UCSF Medical Group, see the grid below for more specific information. Any delegated medical group must submit encounter data to San Francisco Health Plan in lieu of claims. For more information on delegated responsibilities or encounter data please see the Network Operations Manual posted on our website at


Who has financial risk? Shared by BTP and SFHP


& SFHP Kaiser NEMS

Shared by UCSF & SFHP Who processes claims? BTP (Professional) CCHCA SFHP HILL (Professional) Kaiser NEMS SFHP SFHP (Facility & DME) SFHP ( Facility & DME) Claims inquiry phone number BTP (415) 972-6000 (415) 955-8800 Fax: 955-8812 (415) 547-7818 ext. 7115 HILL: (800) 445-5747 Claims and Referrals: Member Services (800) 390-3510 (415) 391-9686 ext. 5241 (415) 547-7818 ext. 7115 SFHP (415) 547-7818 ext. 7115 SFHP: (415) 547-7818 ext. 7115 Claims mailing address BTP: PO Box 640469 SF, CA 94107 445 Grant Ave Ste 700 SF, CA 94133 201 3rd Street, 7th Floor SF, CA 94103 HILL: PO Box 8001 Park Ridge, IL 60068-8001 2425 Geary Blvd, SF, CA 94115 1520 Stockton Street SF, CA 94133 201 3rd Street, 7th Floor SF, CA 94103 SFHP: 201 3rd Street, 7th Floor, SF, CA 94103 SFHP: 201 3rd Street, 7th Floor SF, CA 94103 Who makes UM decisions



a. Electronic Claims

SFHP prefers that claims be submitted electronically in a HIPAA 5010 837-compliant format. For information on file layouts, assistance on submitting electronic claims, or to obtain a copy of the SFHP 837 Companion guide, please contact the SFHP Information Technology Services Department at (415) 615-4411 or email at

b. Checking Claim Status

Providers may check claim status as well as eligibility and authorization status through the Provider Portal. The Provider Portal can be accessed on our website, Providers may also call SFHP’s claim line at (415) 547-7818 ext. 7115.

c. Corrected Claims

Claims denied or rejected for insufficient or incorrect claim forms and /or documentation, can be corrected and resubmitted for processing. For CMS 1500 forms, please write “Corrected Claim” on the top of the form itself. For UB 04 forms, please indicate a corrected claim with the appropriate bill type, XXX7.


Claim Timelines

SFHP complies with AB1455 timeline guidelines. SFHP shall reimburse each complete claim, or portion thereof, whether in state or out of state, as soon as practical, but not later than 45 working days after the date of receipt of the complete claim, unless the complete claim or portion thereof is contested or denied. For more information of the requirements for a complete claim, see section AIV.

Claims submitted through the mail, received after 3:30 pm on any given day are assigned to the following business day’s receipt date. Electronic claims submitted after 10:30 am are assigned to the following business day’s receipt date.

a. Billing Limits



Clean Claims

SFHP will process a clean and complete claim that is submitted in a timely manner for medically

necessary, covered services by a participating provider group in accordance with the agreement between SFHP and the provider group for the applicable benefit program.

A clean claim is defined as a fully completed claim form that contains all the required data elements necessary (including any essential documentation) for accurate adjudication.

For a list of the required fields by form see the following two sections, AV and AVI.

a. Other Claim Requirements

Black Ink on Claims: All claims submitted must be black print and legible. This will prevent claims from being returned. No handwriting or faxes, please.

Font Size: Claims must have a size 10 font or larger but not to exceed the size of the field. Red and White Claims: Claims not submitted on red and white claim forms will not be

adjudicated. They will be returned to the originating service provider.  NDC/UPN: Include whenever applicable.

Quantities: A quantity for each service rendered is required. Please enter quantities as a single digit (e.g., “1” not “01,” “001” or “010”). Please do not use decimals.

Attachments: Individual claim forms are separated. Each claim is processed separately. Do not staple original claims together. Stapling original claims together indicates the second claim is an “attachment,” not an original claim to be processed separately.

Professional/Facility Services: Do not bill both hospital professional and facility services on the same form. If this procedure is not followed, services billed on an incorrect form will be denied. Authorizations: Prior authorization of services is required for someprocedures; see for the most up-to-date list of prior authorization requirements. All

out-of-network referrals (e.g., a CHN member consulting with a UCSF specialist) and inpatient admissions require prior authorizations. Referrals within a member's medical group do not require prior authorization. Please be sure to include a prior authorization number when applicable.


Health Insurance Claim (CMS 1500) Form Instructions

The most current and standard Center of Medicaid and Medicare Services (CMS) 1500 form must be used to bill SFHP for medical services. The form is used by Physicians and Allied Health Professionals to

submit claims for medical services. All items must be completed unless otherwise noted in these instructions. A CMS 1500 form with field descriptions and instructions is shown below.

In order to maintain the highest level of data integrity, SFHP will not add or change any information on a submitted claim (electronic or paper), therefore, the entire claim may be rejected if any of the required data elements are missing or invalid. To submit a corrected claim, see AII.

CMS 1500

Field Required Field? Description and Requirements


1a Required Insured's SFHP ID Number - Enter the member's 11-digit SFHP number as it appears on the ID card. When submitting a claim for a newborn infant for the month of birth or the following month, enter the mother’s ID number in this field. Do not use the SSN or CIN number when billing services. If you do not know the patient's SFHP ID, you can log onto our Provider Portal to look up the patient's ID, see section DVI for more instructions on the Provider Portal.

2 Required Patient's Name - Enter the member’s name as is indicated on the

ID card. When submitting claims for a newborn infant using the mother’s ID number, enter the infant’s name in Box 2. Services rendered to an infant may only be billed with the mother’s ID for the month of birth and the month after. Enter “Newborn using Mother’s ID”/ “(twin a) or (twin b)” in the Reserved for Local Use field (Box 19).

3 Required Patient's Birthdate - Enter member's date of birth and check the

box for male or female.

4 If Applicable Insured's Name - Not required unless billing for an infant using the

Mother’s ID. See #2 above.

5 Required Patient's Address/Telephone - Enter member’s complete address

and telephone number.

6 If Applicable Patient's Relationship to Insured - Only Self or Child are applicable.

7 Optional Insured's Address

8 Optional Reserved For NUCC Use

9 Optional Other Insured's Name

9a Optional Other Insured's Policy/Group Number

9b-c Optional Reserved for NUCC use

9d Optional Insurance Plan/Program Name

10a-c Optional Patient's Condition Related to employment, auto accident/place,

other accident.

10d Optional Claim codes (designated by NUCC)

11 Optional Insured’s policy group or FECA number

11a Optional Insured's Date of Birth/Sex

11b Optional Other claim ID (designated by NUCC)

11c If Applicable Insurance Plan Name or Program Name - For Medicare/Medi-Cal

crossover claims. Enter the Medicare Carrier Code.

11d Required Is there another health benefit plan? Enter an X if recipient has


CMS 1500

Field Required Field? Description and Requirements

exceptions, providers must bill the recipient’s other health insurance coverage prior to billing Medi-Cal. If the Other Health Coverage has paid, enter the amount in the upper right side of this field, do not enter a decimal point or dollar sign.

12 Optional Patients of Authorized Person’s Signature

13 Optional Insured's or Authorized Person's Signature

14 Required Date of Current - Illness (First Symptom) or Injury or Pregnancy

(LMP) - Enter the date of onset of the member's illness, the date of accident/injury or the date of the last menstrual period.

15 Optional Other Date

16 Optional Dates Patient Unable to Work in Current Occupation

17 If Applicable Name of Referring Provider or Other Source - Enter the full name

of the Referring Provider. Data in this field must be indented. The space to the left of the vertical dotted line must remain blank. A referring/ordering provider is one who requests services for a member, such as provider consultation, diagnostic laboratory or radiological tests, physical or other therapies, pharmaceuticals or durable medical equipment.

17a If Applicable Unlabeled

17b If Applicable NPI - Enter Referring Provider's NPI number.

18 If Applicable Hospitalization Dates Related to Current Services - Enter the date

of hospital admission and discharge if the services billed are related to hospitalization. If the patient has not been discharged, leave the discharge date blank.

19 If Applicable Reserved for Local Use - Use this area for procedures that require

additional information, justification or an Emergency Certification Statement.

This section may be used for an unlisted procedure code when explanation is required and clinical review is required.

If modifier “-99” multiple modifiers is entered in section 24d, they should be itemized in this section. All applicable modifiers for each line item should be listed.

Claims for “By Report” codes and complicated procedures should be detailed in this section if space permits.

All multiple procedures that could be mistaken for duplicate services performed should be detailed in this section. Anesthesia start and stop times.

Itemization of miscellaneous supplies, etc.

20 If Applicable Outside Lab? – If this claim includes charges for laboratory work


21 If Applicable Diagnosis or Nature of Illness or Injury - Enter all letters and/or numbers of the ICD-9-CM (ICD-10 effective 10/1/2015) code for each diagnosis, including fourth and fifth digits if present. The first diagnosis listed in section 21.1 indicates the primary reason for the service provided.

Once ICD-10 is implemented, SFHP will require that the ICD indicator be set to zero when using ICD-10 codes.

22 Optional Resubmission Code/Original Ref. No.

23 If Applicable Prior Authorization Number - Enter prior authorization or referral

number. Shaded

Section Above 24

If Applicable Use this area for and NDC/UPN information. These must be

included, if applicable.

24A Required Dates of Service - Enter the date the service was rendered in the

“from” and “to” boxes in the MMDDYY format. If services were provided on only one date, they will be indicated only in the “from” column. If the services were provided on multiple dates (i.e., DME rental, hemodialysis management, radiation therapy, etc.), the range of dates and number of services should be indicated. “To” date should never be greater than the date the claim is received by the Health Plan.

24B Required Place of Service - Enter one code indicating where the service was

rendered. 03 - School

04 - Homeless Shelter

05 - Indian Health Service Free-Standing Facility 06 - Indian Health Service Provider-Based Facility 07 - Tribal 638 Free-Standing Facility

08 - Tribal 638 Provider Based-Facility 11 - Office Visit

12 - Home

13 - Assisted Living 14 - Group Home 15 - Mobile Unit

20 - Urgent Care Facility 21 - Inpatient Hospital 22 - Outpatient Hospital 23 - Emergency Room

24 - Ambulatory Surgical Center 25 - Birthing Center

26 - Military Treatment Facility 31 - Skilled Nursing Facility 32 - Nursing Facility


CMS 1500

Field Required Field? Description and Requirements

34 - Hospice

41 - Ambulance - Land

42 - Ambulance - Air or Water

50 - Federally Qualified Health Center 51 - Inpatient Psychiatric Facility

52 - Psychiatric Facility Partial Hospitalization 53 - Community Mental Health Center 54 - Intermediate Care Facility

55 - Residential Substance Abuse Treatment Facility 56 - Psychiatric Residential Treatment Center 60 - Mass Immunization Center

61 - Comprehensive Inpatient Rehab Facility 62 - Comprehensive Outpatient Rehab Facility 65 - End Stage Renal Disease Treatment Facility 71 - State or Local Public Health Clinic

72 - Rural Health Clinic 81 - Independent Laboratory 99 - Other Unlisted Facility

24C If Applicable Emergency Code: Enter an “X” when billing for emergency services,

or the claim may be reduced or denied.

24D Required Procedures, Services or Supplies/Modifier - Enter the applicable

CPT and/or HCPCS National codes in this section. Modifiers, when applicable, are listed to the right of the primary code under the column marked “modifier”. If the item is a medical supply, enter the two-digit manufacturer code in the modifier area after the five-digit medical supply code.

24E Required Diagnosis Pointer - Enter the diagnosis code letter from box 21

that applies to the procedure code indicated in 24D.

24F Required Charges - Enter the charge for service in dollar amount format. If

the item is a taxable medical supply, include the applicable state and county sales tax.

24G Required Days or Units - Enter the number of medical visits or procedures,

units of anesthesia time, oxygen volume, items or units of service, etc. Do not enter a decimal point or leading zeroes. Do not leave blank as units should be at least 1. For more information on billing requirements of specific services, see section C.

24H If Applicable EPSDT Family Plan - Enter code “1” or “2” if the services rendered

are related to family planning (FP). Enter code “3” if the services rendered are Child Health and Disability Prevention (CHDP) screening related

24I Optional ID Qualifier for Rending Provider

24J If Applicable Rendering Provider ID #/ NPI - Enter the NPI for a rendering


25 Required Federal Tax ID Number - Enter the Federal Tax ID for the billing provider. (Note: if vendor tax ID # is shared between two or more individual vendors, the provider must submit claims using a SFHP-issued 3-digit suffix addition to the Tax ID number).

26 Optional Patient's Account Number -Enter the patient’s medical record

number or account number in this field. This number will be reflected on Remittance Advice (RA), if populated.

27 Optional Accept Assignment?

28 Required Total Charge -Enter the total for all services in dollar and cents. Do

not include decimals. Do not leave blank.

29 If Applicable Amount Paid - Enter the amount of payment received from the

Other Health Coverage. Enter the full dollar amount and cents. Do not enter Medicare payments in this box. Do not enter decimals.

30 If Applicable Balance Due - Enter the difference between the Total Charges and

the Amount Paid in full dollar amount and cents. Do not enter decimals.

31 Required Signature of Physician or Supplier Including Degrees or Credentials

- The claims must be signed and dated by the provider or a representative assigned by the provider in black pen. An original signature is required. Stamps, initials or facsimiles are not


32 Required Service Facility Location Information - Enter the provider name.

Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number of the facility where services were rendered, if other than home or office.

32a Required Service Facility Location Information - Enter the NPI of the facility

where the services were rendered.

32b If Applicable Service Facility Location Information - Enter the Medi-Cal provider

number for an atypical service facility.

33 Required Billing Provider Info & Phone # (Pay-To) - Enter the provider name.

Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number.

33a Required Enter the billing provider’s NPI.

33b Required Used for atypical providers only. Enter the Medi-Cal provider

number for the billing provider.


Health Insurance Claim Form (UB04) Instructions


will be returned to the originating service provider. A UB04 form with field descriptions and instructions is shown below.

In order to maintain the highest level of data integrity, SFHP will not add or change any information on a submitted claim (electronic or paper), therefore, the entire claim may be rejected if any of the required data elements are missing or invalid. To submit a corrected claim, see AII.

UB-04 Field Required Field? Description and Requirements

Inpatient Outpatient

1 Required Required Rendering Provider Name and Address - Enter the

provider name, address and zip code and telephone number this section.

2 Required Required Pay - To Provider Name and Address - Enter the provider

name, address and zip code and telephone number this section.

3a Optional Optional Patient Control Number - This number is reflected on

the Explanation of Benefits for reconciling payments if populated.

3b Optional Optional Medical Record Number - Not required. This number

will not be reflected on RA if populated.

4 Required Required Type of Bill - Enter the appropriate four-character type

of bill code as specified in the National Uniform Billing Committee (NUBC) UB-04 Data Specifications Manual.

5 Required Required Federal Tax Number - Enter the Federal Tax ID for the

billing facility. (Note: If vendor tax ID # is shared between two or more individual vendors, the provider must submit claims using a SFHP-issued 3-digit suffix addition to the Tax ID number).

6 Required Required Statement Covers Period - Enter the “From” and

“Through” dates of services covered on the claim if claim is for inpatient services.

7 Optional Optional Future Use

8a Optional Optional Patient Name - Enter patient’s name in 8b.

8b Required Required Patient Name - Enter patient’s last name, first name and

middle initial if known. When submitting claim for a newborn using the mother’s ID, enter the infant’s name in box 8b. If the infant is unnamed, write the mother’s last name followed by “baby boy” or “baby girl”. If billing for multiple births, use “twin A”, “twin B”, etc. on separate claim forms.

9 Optional Optional Patient Address

10 Required Required Patient Birthdate - Enter the patient’s date of birth in an

eight digit format, Month, Date, Year (MMDDYYYY) format.


for female.

12 Required Required Admission Date - Enter in a six-digit format (MMDDYY),

enter the date of hospital admission.

13 Required Required Admission Hour - Enter hour of patient's admission.

14 Required Required Admission/Visit Type - Enter the numeric code indicating

the necessity for admission to the hospital. 1 - Emergency

2 - Elective

15 If Applicable If Applicable Admission Source - If the patient was transferred from

another facility, enter the numeric code indicating the source of transfer.

1 - Non-Healthcare Facility Point of Origin 2 – Clinic

4 - Transfer from a Hospital (Different Facility) 5 - Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)

6 - Transfer from Another Healthcare Facility 7 - Emergency Room

8 - Court/Law Enforcement 9 - Information Not Available

B - Transfer from Another Healthcare Facility C - Readmission to the same Home Health Agency D - Transfer from one distinct unit of the hospital to another distinct unit of the same hospital resulting in a separate claim to the payer

E - Transfer from Ambulatory Surgery Center

F - Transfer from Hospice and is under a hospice plan of care or enrolled in a hospice program

16 Required n/a Discharge Hour - Enter the discharge hour. For Inpatient


17 Required Required Patient Discharge Status

18 - 28 Optional Optional Condition Codes - Enter the Medi-Cal codes used to

identify the condition relating to this bill and affect payer processing.

Condition Codes covered by SFHP: 80 - Other Coverage

81 - Emergency Certification A1 - CHDP Screening Related A3 - Family Planning/Sterilization A4 - Family Planning/Other

29 If Applicable If Applicable Accident State - If visit or stay is related to an accident,

enter in which state the accident occurred.


UB-04 Field Required Field? Description and Requirements

Inpatient Outpatient

31 - 34 If Applicable If Applicable Occurrence Codes and Dates - Enter the codes and

associated dates that define the significant event related to the claim.

Occurrence Codes covered by SFHP: 01 - Auto Accident

02 - No Fault Insurance Involvement - Including Auto Accident/Other

03 - Accident/Tort Liability 04 - Employment Related 05 - Other Accident 06 - Crime Victim

35 -36 Optional Optional Occurrence Span Codes and Dates

37 Optional Optional Internal Control Number/Document Control Number

38 If Applicable If Applicable Responsible Party Name and Address - Enter the name

and address of the party responsible for payment if different from name in box 50.

39 - 41 Optional Optional Value Codes and Amounts

42 Required Required Revenue Code - For inpatient billing, enter the four-digit

revenue code for the services provided, e.g. room and board, obstetrics, etc.

43 Required Required Revenue Description - Identify the description of the

particular revenue code in box 42 or HCPCS code in box 44. Include NDC/UPN Codes here, when applicable.

44 Required Required HCPCS/Rates - Enter the applicable HCPCS codes and

modifiers. For outpatient billing do not bill a

combination of HCPCS and Revenue codes on the same claim form. When billing for professional services, use CMS 1500 form.

45 Required Required Service Date - Enter the service date in MMDDYY format

for outpatient billing.

46 Required Required Units of Service -Enter the actual number of times a

single procedure or item was performed or provided for the date of service.

47 Required Required Total Charges (By Rev. Code)

48 Optional Optional Non-Covered Charges

49 n/a n/a Future Use

50 Required Required Payer Identification (Name) - Enter “San Francisco Health

Plan” and the corresponding medical group that the member belongs to.

51 Optional Optional Health Plan ID

52 Optional Optional Release of Info Certification

53 Optional Optional Assignment of Benefit Certification

54 If Applicable If Applicable Prior Payments - Enter any prior payments received from


55 Optional Optional Estimated Amount Due

56 Required Required NPI - Enter NPI number.

57 Optional Optional Other Provider IDs

58 If Applicable If Applicable Insured's Name - Enter the mother’s name if billing for

an infant using the mother’s ID. If any other circumstance, leave blank.

59 If Applicable If Applicable Patient's Relation to Insured -Enter “03” (child) if billing

for an infant using the mother’s Identification Number.

60 Required Required Insured's Unique ID - Enter the patient’s 11-digit SFHP ID

number as it appears in the member’s ID card. Enter the mother’s ID number in this section for a newborn infant for the month of birth and the month after only. Do not use the SSN or CIN.

61 Optional Optional Insured Group Name

62 Optional Optional Insured Group Number

63 If Applicable If Applicable Treatment Authorization Code - Enter any authorizations

numbers in this section. It is not necessary to attach a copy of the authorization to the claim. Member information from the authorization must match the claim.

64 Optional Optional Document Control Number

65 Optional Optional Employer Name

66 Required Required Diagnosis/Procedure Code Qualifier use 9 for ICD-9

codes, and 0 for ICD-10 codes

67 Required Required Principal Diagnosis Code/ Other Diagnosis Codes - Enter

all letters and/or numbers of the ICD-9 CM (ICD-10 effective 10/1/2015) code for the primary diagnosis including the fourth and fifth digit if present.

68 If Applicable If Applicable Other Diagnosis Codes - Enter all letters and/or numbers

of the secondary ICD-9 CM (ICD-10 effective 10/1/2015) code including fourth and fifth digits if present. Do not enter a decimal point when entering the code.

69 If Applicable If Applicable Admitting Diagnosis Code

70 Optional Optional Patient's Reason for Visit Code

71 Optional Optional PPS Code

72 Optional Optional External Cause of Injury Code

73 Optional Optional Future Use

74 If Applicable If Applicable Principal Procedure Code/Date

75 n/a n/a Future Use

76 If Applicable If Applicable Attending Name/ ID-Qualifier 1G

77 If Applicable If Applicable Operating ID

78 - 79 If Applicable If Applicable Other ID


UB-04 Field Required Field? Description and Requirements

Inpatient Outpatient

81CC Optional Optional Code - Code Field/Qualifiers.


Other Insurance/Coordination of Benefits

Some SFHP members have other health coverage (OHC) in addition to their SFHP coverage. Specific rules govern how benefits must be coordinated in these cases. For information on member eligibility and program descriptions, please see the Network Operation Manual on

State and Federal laws require that all available health coverage be exhausted before billing Medi-Cal. Thus, when a SFHP member has other health coverage and has Medi-Cal, SFHP will always be the payer of last resort.

Other Health Coverage includes any non Medi-Cal health coverage that provides or pays for health care services. This can include:

 Commercial Health Plans (individual and group policies)

 Prepaid Health Plans

 Health Maintenance Organizations (HMO)

 Employee benefit plans

 Union Plans

 Tri-Care, Champ VA

 Medicare, including Medicare Part D plans, Medicare supplemental plans and Medicare

Advantage (PPO, HMO and Fee for Service) plans.

When a SFHP member also has OHC, s/he must treat the other insurance plan as the primary insurance company and access services under the company’s rules of coverage. SFHP is not liable for the cost of services for members with OHC who do not obtain the services in accordance with the rules of their primary insurance. If a member elects to seek services outside of the framework of his or her primary insurance, the member is responsible for the cost.

If other insurance is primary and SFHP does not pay as primary, procedures which normally require prior authorization will not be required. However, SFHP requires authorization of admission for skilled nursing facilities, long term care facilities and inpatient admissions.

To coordinate benefits for a patient who has dual coverage, you must bill the primary insurance first. If there is any balance remaining after payment is received from the primary insurer, you should submit a claim to San Francisco Health Plan or the appropriate Medical Group responsible along with the

Explanation of Benefits (EOB) from the primary payer. If your claim is denied for no EOB, you may resubmit the claim; see section AII for more information.

San Francisco Health Plan reimburses Medicare and Medi-Cal eligible providers for applicable deductible and coinsurance, if the collective payment of Medicare and Medi-Cal does not exceed Medi-Cal’s

reimbursement rates. For members with Medicare and Medi-Cal coverage, please submit the following:

 For UB-04 claims, please submit the Medicare National Standard Remittance Advice.


exceptions to this are: 1) Healthy Workers with timely filling; and 2) When the member has Medicare Part D.


Third Party Liability

If a member is injured through the act or omission of another person (a third party), SFHP will, with respect to services required as a result of that injury, provide covered services to its members, but the member shall agree to the following:

 Agrees to reimburse SFHP the reasonable cash value of benefits provided as reflected by the

physician's usual and customary charges and as allowed by law, immediately upon collection of damages by the member, whether by action at law, settlement, or otherwise

 Provides SFHP with a lien, in an amount equal to the value of benefits provided by SFHP, as

reflected by an amount not to exceed eighty (80) per cent of the provider's usual and customary charges or the amount actually paid by SFHP. The lien may be filed with the third party, the third party's agent, or the court

 All liens filed by SFHP for the recovery of payments made by SFHP on behalf of a member entitled

to medical services under the Plan shall be in accordance with Civil Code section 3040

 For Medi-Cal members, the State Department of Health Care Services (DHCS), and not SFHP, has



In the Claims Coding Section you will find coding

requirements to assist you in billing correctly for services

rendered to SFHP members.

1. Overview of Codes

2. Procedure Codes

3. Healthcare Common Procedure Coding System (HCPCS) Codes

4. Diagnosis Codes

5. Modifiers

6. Multiple Procedures or Visits

7. By Report Procedures

8. National Drug Codes (NDC)and Unique Product Numbers (UPN)




Overview of Codes

San Francisco Health Plan uses Medi-Cal billing guidelines in addition to Optum coding books for claim

activities. Additional coding information and updates can be found on the AMA website at

The following procedure codes must be used for a claim to be processed:

 Professional charges – HIPAA compliant HCPCS Level 1 (CPT) & level 2

 Inpatient hospital/facility/institutional charges – UB04 revenue codes

 Outpatient hospital/facility charges – HCPCS Level 1 & 2 codes

 HCPCS Level 3 codes will no longer be accepted for dates of service on or after 10/1/14

Professional and institutional charges must be submitted as separate claims. If submitted on the same claim, one or the other type of charges will not be considered for payment. For example, if professional charges (CPT codes) are included on an institutional claim for an inpatient stay, then these charges will be automatically bundled under the per-diem payment.

The following includes special instructions regarding the use of various codes for different types of services. CPT codes, rather than HCPCS codes, should be used as first line coding when an appropriate code exists.


CPT-4 Professional Services

HCPCS I Physician Services

HCPCS II Non-physician procedures and services

HCPCS III California only


Revenue Codes Inpatient facility services


CPT Codes

Report ambulatory surgery, outpatient department visits, diagnostic testing and ancillary services using CPT, HCPCS Level II and III codes. Claims submitted with invalid, incorrect or missing procedure codes will be denied.

Procedure CPT or HCPCS

Surgery 10000-69999

Radiology 70000-79999

Pathology & Laboratory 80000-89999

Medicine 90281-99199

Evaluation & Management 99201-99499



Conflicts with Other Common Core Data

Claims are screened for conflicts with other patient and/or provider information. Reimbursement will not be made for claims where CPT procedure codes conflict with common core data, such as:

 Patient age/gender

 Diagnosis

 Place of service

 Provider specialty

b. Unlisted Services and Procedures

Claims for services submitted with unlisted CPT procedure codes (XXX99) require the following:

 Invoices of other pertinent information for DME, etc.

 Medical records for surgical procedures

 Documentation/Remarks or itemization of supplies

 Authorization


Age Parameters

Claims are processed according to the following age parameters as defined by Medi-Cal.

Age range Classification

up to 17 years Pediatric (infant, children and adolescent) patients

18 years and older Adult patients


Healthcare Common Procedure Coding System (HCPCS) Codes

The Healthcare Common Procedure Coding System (HCPCS) is a national, uniform coding structure developed by the Centers for Medicare & Medicaid Services (CMS) to standardize the coding systems used to process Medicare and Medicaid (Medi-Cal) claims on a national basis. HCPCS is a three-level coding system that incorporates Physicians’ Current Procedural Terminology (CPT-4), National and Local codes.

The HCPCS coding format for Level I is five-digit numeric. The format for Level II and III is an alpha character followed by four numeric digits. The full range of codes for each level is as follows: Level I is 00100 thru 01999 and 10000 thru 99999; Level II is A0000 thru V9999.

The existence of a specific Level II HCPCS code for a particular item or service is not a guarantee that the item or service is covered by SFHP. Refer to the section in the Medi-Cal Provider Manual specific to the service rendered for Medi-Cal reimbursable Level II.


Diagnosis Codes

SFHP requires a valid diagnosis code with each claim. Claims submitted with invalid, incorrect or missing diagnosis codes will be denied.


Use V codes, the supplementary classification of factors influencing health status in accordance with ICD-9-CM V-code reporting guidelines.

Use E codes, the supplementary classification of causes of injury and poisoning in accordance with ICD-9-CM E code reporting guidelines.

CMS requires all entities to use ICD-10 diagnosis codes for any dates of service on or after October 1, 2015.

Claims are screened for conflicts with other patient and/or provider information. Reimbursement will not made for claims where Diagnosis procedure codes conflict with common core data, such as:

 Patient age/gender

 CPT code

 Place of service

 Provider specialty



Modifiers are "the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance, but not changed in its definition or code.” Although many procedure codes require a modifier, some procedures do not need further clarification via a modifier. The inappropriate use of a modifier may result in the claim being denied. We follow current approved HIPAA compliant modifiers and consult Medi-Cal guidelines for appropriate coding.


Multiple Procedures or Visits

In general, only one visit or consultation per specialty is reimbursed for the same date of service. When two or more visits/consultations are billed for the same date of service, remarks should be made and they will be reviewed for individual consideration. Please ensure to use the appropriate member ID, rendering physician NPI (s), dates of service, service code(s) and modifiers when billing for more than one service on the same date of service.

Multiple surgery procedure codes (CPT 10000-69999) for the same patient, for the same date of service, are required to be coded following Medi-Cal guidelines. .


statement indicating, “this service is not a duplicate” is not sufficient to clarify why the service was rendered more than once.

For more information on duplicate billing, see section CX.


By Report Service/HCPCS Codes

This section includes information about “By Report” procedures, attachments and documentation. The following applicable information must be included in either Box19 of the CMS 1500, Box 84 on the UB04 form or provided as an attachment to the claim form:

 Invoice should include item description, manufacturer name, model number, catalog number,

manufacturer suggested retail price (MSRP), if applicable.

 Operative report, operating time or procedure report including a description of the actual

procedure performed and the results of the procedure.

 Number, size and location of lesions (if applicable).

 Time involved, the nature and purpose of the procedure or service and how it relates to the

diagnosis. Description of and justification for any special features, custom modifications, etc.

The reason a listed code was not used. Itemization of miscellaneous supply codes, etc.


National Drug Codes (NDC) and Unique Product Numbers (UPN)

a. National Drug Code (NDC):

The Federal Deficit Reduction Act of 2005 (DRA) requires Medi-Cal to collect rebates from drug manufacturers for physician-administered drugs. The collection of rebates is accomplished with the inclusion of National Drug Codes (NDCs) on claims submitted by providers.

Effective for claims with dates of service on or after April 1, 2009, providers must use NDC for physician-administered drugs, in conjunction with the customary Healthcare Common Procedure Coding System (HCPCS) Level I, II or III code, on all Medi-Cal claims. Claims will be denied if providers do not submit claims with a valid NDC paired with the appropriate HCPCS code as mandated by the NDC reporting requirement. Please note, HCPC level III codes will no longer be accepted on 10/1/14.

Physician-administered drugs include any covered outpatient drug billed by a provider other than a pharmacy. This includes (but is not limited to) the following provider types:

 Physicians

 Clinics

 Hospitals

The NDC reporting requirement applies to claims submitted using the following formats:

 837 electronic transactions for Institutional and Professional claims



This section was developed to assist you in understanding

key claim requirements and policies.

1. Professional Services

2. Laboratory and Pathology

3. Ambulance Services

4. Vision Services

5. Inpatient Services

6. Facility Outpatient Billing

7. Medical Supply Billing Requirements

8. Emergency Room Services

9. Immunizations

10. Duplicate Billings

11. SFHP Covered Benefits

12. Services Covered by Other Entities

13. Sensitive Services and Diagnosis




Professional Services

SFHP reimburses providers for professional services. Professional services should be obtained within the member’s network. Most professional services rendered outside of the member’s network require prior-authorization. Emergency services, Family Planning and Sensitive Services do not require prior

authorization. Professional services should be billed on a CMS 1500 claim form and should be submitted to the Member’s Medical group or SFHP as referenced in Section A1 of this claims manual.

a. Gynecological and OB Services

SFHP members may access obstetric and gynecological services directly from an OB/GYN specialist or family practitioner within the member’s network. This includes all services provided by a network OB/GYN, including prenatal and Comprehensive Perinatal Services Program (CPSP) services.

The Comprehensive Perinatal Services Program (CPSP) offers a wide range of services to pregnant Medi-Cal SFHP members from the date of conception through 60 days after the month of delivery. Member and provider participation is voluntary. CPSP codes can be used by CPSP certified providers only. CPSP frequency limits apply. All visits over the allowed number of visits are subject to authorization.

SFHP does not allow Global Billing for Obstetrical Services. OB services should be billed on a per-visit basis.

Additional information regarding CPSP, obstetric and gynecological billing can be found at

b. Anesthesia

SFHP reimburses anesthesia services to providers for induction of general or regional anesthesia and supportive services associated with the provision of optimal anesthesia care for medical or surgical procedures.

SFHP reimburses anesthesia services using the Anesthesia Unit System. SFHP requires the following for Anesthesia billing:

 Services are reimbursed using the surgical CPT code or anesthesia codes. Complete the CMS 1500

form using the surgical anesthesia services CPT code representing the major procedure performed with the appropriate HCPCS anesthesia modifier.

 If an unlisted (not otherwise specified) CPT code is used, submit documentation of the operative

procedure with the claim.

 Services are reimbursed by determining the sum of the allowable base and time units.

o Base values as defined by the American Society of Anesthesiologists (ASA); SFHP

automatically assigns base values from Medi-Cal fee schedule.

 A time unit of fifteen (15) minutes or a portion thereof. Each 15-minute increment equals one


o Anesthesia time starts when the anesthetist begins to prepare the patient for induction


o Enter the number of 15 minute increments of anesthesia time in the Service Units/Days box (24G). The last anesthesia time increment rendered may be rounded to a whole unit if it equals or exceeds five minutes, it may not be billed as an additional anesthesia time unit.

 Submit paper claims with the elapsed time in minutes.


Laboratory and Pathology

SFHP reimburses technical, professional laboratory and pathology services when rendered by a

contracted provider at approved clinical and diagnostic laboratories or authorized by SFHP or delegated medical group..

SFHP reimburses:

 Panel codes, when all individual tests included in the panel have been performed

 Individual codes, when all components in a panel have not been performed

 Clinical laboratory tests, when performed by a technician under physician

 Some laboratory and pathology consultant opinions, when the test results are outside the normal

or expected range and the ordering physician requests additional outside testing SFHP does not reimburse:

Specimen collection or venipuncture charges made in conjunction with laboratory services or evaluation and management services are not reimbursable.


 Complete the CMS 1500 form using appropriate CPT and HCPCS codes for laboratory and

pathology services performed in a non-institutional setting

 Bill using the appropriate modifiers for the services rendered


Ambulance Transport

SFHP reimburses licensed ambulance companies for emergency transportation, without an authorization required, and can include other necessary services such as mileage and ECG. The claim must contain the emergency code on the claim form. Please submit claims with supporting documentation for emergency transportation via mail. For non-emergency transportation, a prior authorization is required.

Please refer to Medi-Cal guidelines and provider manuals for the most up to date information.


Vision Services

SFHP will reimburse medically-related vision service rendered to SFHP members. Please visit, to determine if a prior authorization for medically-related vision services is required. All other vision-related services should be billed directly to Vision Service Plan (VSP).


by the hospital to SFHP or the designated Medical Group is required for all inpatient admissions. Notification of admission is required before providing post stabilization care to a patient with an emergency condition. The hospital must request authorization for post stabilization care (AB 1203).

a. Admission Date

The admission date determines all inpatient reimbursement terms. When admission dates bridge contract effective dates, the contracted rate will be applied to those dates on or after the contract effective date.

Determination of inpatient status occurs at the date and time the admitting physician writes the order to admit the member to inpatient status and when the member’s clinical status meets SFHP’s criteria for inpatient care.

b. Membership Date

No reimbursement will be made after a SFHP member terminates membership with the San Francisco Health Plan, even if the member is an inpatient in the hospital on the date of termination.

SFHP reimburses inpatient care (except for Organ Tissue Procurement and Factor 8) at a single per-diem inclusive rate when prior authorization is approved and when notified within appropriate timeframes. All services provided within 24 hours of an inpatient admission that are related to the principal diagnosis are included in the inpatient per diem reimbursement. Reimbursement includes:

 Operating room services

 Recovery room services

 Ancillary services

 Room and board

 Nursing care

 Supplies and therapeutic items (drugs and biologicals)

 Appliances and equipment

 Diagnostic services

SFHP does not separately reimburse:

 Blood or blood products associated with surgery

 Personal services, telephone calls, televisions and guest trays

c. Billing

Complete the UB04 using the appropriate inpatient services revenue codes and diagnosis codes. When applicable, enter the authorization number in box 63. All professional services should be billed on a CMS 1500 form using the appropriate CPT/HCPCS and diagnosis codes.

d. Compensation Conditions

Compensation shall be on a fee-for service basis; providers shall be paid the rates pursuant to the Medical Group contract or negotiated rate. Reimbursement shall be based exclusively on medically necessary services and authorized levels of care. One per diem is payable for each:


 Member admitted and discharged during the same day, provided that such admission and discharge are not within 24 hours of a prior discharge

 Mother and newborn child (children) when both mother and newborn child (children) are in the

hospital on the same day, unless the child (children) is in the neonatal intensive care unit


Facility Outpatient Billing

Prior notification by the hospital to SFHP or the designated Medical Groups is required for all facility outpatient services.

Complete the UB04 using the appropriate outpatient facility HCPCS codes and diagnosis codes. If applicable, enter the authorization number in box 63. Professional services should be billed on a CMS 1500 form using the appropriate CPT/HCPCS and diagnosis codes.


Medical Supply Billing Requirements

Please submit medical supply claims as a paper claim via mail. The medical supply billing requirements, impact Durable Medical Equipment (DME) and Pharmacy providers, include:

 Discontinuing the use of local medical supply billing codes as of 10/01/14.

 HCPCS Level II codes are required for all disposable and incontinence medical supplies

 A Universal Product Number (UPN) is required for all contracted items

 Only product identification numbers listed in the Medi-Cal provider manual under “UPN” will be

acceptable for billing purposes

 Invoice should include item description, manufacturer name, model number, catalog number,

manufacturer suggested retail price (MSRP), if applicable.

 Itemization of miscellaneous supply codes, etc.


Emergency Room Services

SFHP reimburses emergency room (ER) services when a member has a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

 Serious jeopardy to the health of the individual, or in the case of pregnant women, to the health

of the woman or her unborn child

 Serious impairment to bodily functions

 Serious dysfunction of any bodily organ or part

ER care is reimbursed on a fee-for service basis and includes all facility services directly related to the services provided as part of the emergency room care (i.e., pharmacy, ancillary and supplies).

ER care is a covered benefit, regardless of network. The member's emergency room co-payment is waived when emergency care results in an inpatient admission. Emergency care that precedes an


professional services rendered in the emergency room facility. All surgical procedures performed in the emergency room must be billed using the appropriate CPT and HCPCS codes. For more information on where to submit emergency room service claims, please see section AI.



a. Federal Vaccines For Children (VFC)

The Federal Vaccines for Children (VFC) program supplies free vaccines to Medi-Cal enrolled physicians. Every Medi-Cal-eligible child younger than 19 years of age may receive vaccines supplied by the VFC program. To participate, providers must enroll in VFC even if already enrolled with Medi-Cal or the Child Health and Disability Prevention (CHDP) Program. Immunization services must be billed using the

appropriate CPT code. For additional information regarding VFC please refer to Medi-Cal Website for the most up-to-date information.

CPT Codes with Modifier -SL (State Supplied Vaccine)

Providers must use a VFC-provided vaccine when available, and use modifier -SL with the CPT code to bill for these immunizations. VFC providers who bill modifier -SL with the CPT codes will be reimbursed only the Medi-Cal VFC program administration fee.

Note: Medi-Cal providers who are not VFC providers cannot use modifier -SL because this service is available only for VFC providers.

Providers are required to bill using a modifier -SK with the CPT-4 codes if the recipient is at high risk for the disease or condition for which the immune globulin/vaccines/toxoid is given. Providers are required to document in the recipient's medical record the medical reason why the recipient is "high risk" for the disease or condition for which the injection was administered. Providers are no longer required to submit the reason for high risk on the claim, but must do so on the medical record. Please refer to: for additional information.

b. Non VFC Vaccines

Healthy Kids and Healthy Workers members do not qualify for the VFC program. Please send your claims to SFHP.

For Medi-Cal SFHP will cover some vaccine serums that do not fall under VFC either administered by the PCP or rendered in the ER, see Medi-Cal guidelines for specific reimbursement information.


Duplicate Billings

Identical services billed for the same date of service are considered duplicate billings, and only one, service will be reimbursed. SFHP uses the following fields to identify duplicate billing: member ID, dates of service, service codes and modifiers. If you are billing for multiple procedures or visits on the same date of service, ensure to include the appropriate modifiers, rendering provider NPI, and supporting documentation. For more information on how to bill for multiple procedures or visits, see section BVI. If you feel your claim was incorrectly denied for duplication, please contact Provider Relations,



SFHP Covered Benefits

For the most up-to-date information on covered benefits, by line of business, see


Services Covered by Other Entities

When a member qualifies for services that may be covered through another entity, San Francisco Health Plan requires the remittance advice from the other entity before considering reimbursement. Entities San Francisco Health coordinates with include, but are not limited to:

 California Children’s Services — services are reimbursed through CCS

 Golden Gate Regional Center

 Dental Services — services provided through Denti-Cal

 Vision Services, including refraction – Service are reimbursed through VSP

 Most Major Organ transplants — members are disenrolled to Fee for Service Medi-Cal

 SNF – SFHP covers the month of and the month following admission; members are then

disenrolled to Fee for Service Medi-Cal

 Inpatient Mental health services — services provided through SF county Mental Health


Sensitive Services and Diagnosis

Sensitive services do not require authorization and include family planning services (birth control pills, IUDs, etc.), pregnancy testing, sexually transmitted disease (STD) screening, diagnosis or treatment (e.g. Chlamydia, etc.), testing for HIV, sexual assault (rape or sexual abuse). Family planning services are identified by the CPT code or diagnosis.

For sterilization services, the PM330 consent form is required to process the claim for payment. Please attach the consent form to the claim and submit through the mail.

These sensitive services should be billed with an approved sensitive service diagnosis code. The sensitive service diagnosis code must be listed as the first diagnosis code in order to not require authorization. Abortions using general anesthesia under 12 weeks of gestation are excluded from this requirement. Healthy Families and Healthy Kids members are excluded from any of these out of network services; all services are to be provided within member’s designated provider group.

SFHP will automatically adjudicate claims based on Sensitive Service criteria. This is based on the primary diagnosis as related to the approved list of Sensitive Service diagnosis codes. For more information about

what qualifies as a sensitive service or family planning, see You can also find




This section will provide you with steps to take if you

need information on an open claim and how to request a

review or make an appeal on a claim.

1. Claim Status Requests

2. Notice of Action Letters

3. Claim Recoveries

4. Provider Dispute Resolutions (PDRs)

5. Balance Billing

6. Fraud, Waste and Abuse


Contract Information



Claims Status Requests

Inquiries regarding claims, including “tracers”, are welcome sixty (60) days after the initial claims submission. Duplicate claims submitted prior to sixty (60) days may cause delays in processing your claims. Claim status can be checked through the Provider Portal on our website at www.

Providers may contact the SFHP Claims department at (415) 547-7818 ext. 7115 or to

discuss concerns regarding claims submissions.

A request for reconsideration of the claim must be submitted within one (1) year from the date of the Remittance Advice (RA) on which the claim appeared as denied. Any errors on the original claim should be corrected at this time. Timeliness limits will apply if the appropriate follow-up time is not

acknowledged. If it is determined that the claim was handled correctly based on the information and documentation received by SFHP, the provider will be advised of the proper procedure for further claim dispute. For information on how to submit a corrected claim, see section AIIc.


Notice of Action Letters for Member Denials

San Francisco Health Plan and its delegated medical groups are responsible for notifying Medi-Cal, Healthy Kids and Healthy Workers members of denials of payment on emergency and family planning claims. A Notice of Action letter is sent to the member on each emergency and family planning claim that is denied. The Notice of Action letter informs the member of a claim denial, including the reason for the denial.


Claim Recoveries

As a provider of Medi-Cal health care services and as a Knox-Keene licensed health care services plan for Medi-Cal, Healthy Kids and Healthy Workers; San Francisco Health Plan is responsible to meet State guidelines and regulations ensuring qualitative, cost effective service delivery to our members and

providers. It is also necessary to prove fiscal prudence and payment accuracy in reimbursements made to providers for services rendered per guidelines set forth in the California Code of Regulations, Title 22, Sections 50761, 53866.

When an overpayment is identified, either by San Francisco Health plan or the provider’s business office, we will recover the payments that were made in error by requesting that the provider issue a lump sum check payable to San Francisco Health Plan and mail to:

San Francisco Health Plan ATTN: Recoveries 201 Third Street, 7th Floor

San Francisco, CA 94103

Alternatively, the overpayment is reversed from monies due to the provider until the overpayment is recovered.


a claim, billing or contract determination. A Provider Dispute Resolution Request must be submitted in writing using the Provider Dispute Resolution Request Form or by letter, clearly identifying what is being disputed and the expected outcome. Dispute requests must be submitted within 365 days of SFHP’s most recent action regarding the disputed claim.

SFHP recommends that the following information be submitted with all dispute requests to help expedite the resolution process:

 A Complete SFHP Provider Dispute Resolution Request Form (Available on SFHP’s website,

 SFHP Original Claim Number

 SFHP Member ID Number

 Applicable Medical Records

 Correspondence Address

If SFHP does not receive enough information to identify the claim that is being disputed or to make a determination, an Amended Dispute may be requested. In order to ensure that a dispute is processed as quickly as possible, please submit all documentation that may affect the outcome of the dispute as soon as possible.

Disputes must be submitting in writing to the following address: San Francisco Health Plan

Attn: Provider Disputes 201 Third Street, 7th Floor San Francisco, CA 94103

SFHP will issue a written letter acknowledging the receipt of the dispute within 15 business days of the dispute’s receipt. A written determination letter will be issued within 45 business days of the dispute’s receipt.

SFHP recommends contacting our Claims or Provider Relations Departments before submitting a formal dispute, as some issues may be resolved over the phone.


Balance Billing

Participating providers are prohibited from balance billing any member for covered services on all lines of business, except Healthy Workers, for which SFHP is financially responsible. However, other than specific requirements under Medi-Cal for dual eligibles, SFHP is not financially responsible for co-payments, therefore providers may bill the member for a co-payment.



Fraud, Waste and Abuse

Health care fraud is defined as a deception or misrepresentation that an individual or entity makes knowing that the deception or misrepresentation could result in some unauthorized benefit to the individual, entity, or some other party. Medi-Cal considers fraud to be an “intentional attempt by some providers, and in some cases beneficiaries, to receive unauthorized payments or benefits from the program”. Abuse may also result in unauthorized payments or benefits, but is considered to have occurred without the intent.

Common types of fraud within managed care include submission of false claims for services not

performed (or for more expensive services than actually provided), denial of medically necessary

services, deceptive enrollment practices, and receipt of services an individual is not entitled to receive.

 If you suspect any fraud, waste or abuse, please contact San Francisco Health Plan’s Compliance

Officer at Compliance Hotline, (415) 547-7835

 Compliance Officer, (415) 615-4217


a. Claims Department

In the payment of claims there is a potential for provider and employee fraud. The SFHP Compliance Officer will work with representatives from the Claims department to review claims periodically in order to search for potentially fraudulent claims, using an established auditing tool. The Compliance Officer will keep a written record of all random audits of claims and any employee reports of non-compliant or fraudulent provider conduct.

b. Compliance Department

The Compliance Department is responsible for the Compliance Program and related policies and

procedures. The Compliance Officer is responsible for investigating all allegations for fraud, privacy and security breaches, and working in collaboration with other SFHP departments. If necessary, the

Compliance Officer submits the mandated reports about breaches, fraud and abuse cases to State and federal agencies. To report breaches or cases of fraud or abuse, or if you have questions, please contact the Compliance Department:

 Compliance Hotline, (415) 547-7835

 Compliance Officer, (415) 615-4217



Contact Information

Questions About

Who to Call

Tools to Use

Member Eligibility

Customer Service

(800) 288-5555 or (415) 547-7800

Provider Portal


Utilization Management Department

(415) 547-7818 ext. 7080



Claims Department

(415) 547-7818 ext. 7115

Provider Portal

Provider Portal

Provider Relations

(415) 547-7818 ext. 7084

Provider Disputes

Claims Department

(415) 547-7818 ext. 7115

Authorization Appeals

Utilization Management Department

(415) 547-7818 ext. 7080

Remittance Advice

Claims Department

(415) 547-7818 ext. 7115

Provider Portal

Privacy and Security


Compliance Department

(415) 615-4217

Potential fraud, waste

and abuse




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