Claims Submission
Claims Operations Manual, for Claims and IT staff. Claims Manual FAQ
Submit Electronic Claims for free with clearinghouse OfficeAlly.
You can also submit electronic claims in the Provider Portal.
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National Provider Identifier
SFHP requires your billing NPI in its system to process claims and/or encounters. This form is not a provider contract. Please complete the National Provider Identifier form with a copy of your IRS-W9 form and send to:
San Francisco Health Plan
Provider Relations
Fax: 1(415) 615-6450
P.O. Box 194247
San Francisco, CA 94119-4247
To avoid delays in the processing of claims and correspondence, please ensure that all requested documentation is submitted timely. Please allow five business days for the processing of your request.
Claim Forms
Below are links to instructions on how to complete the CMS 1500 and UB-04 Claim Forms. This is for your reference only if you have the need for a refresher or want to look up anything specific regarding completing the claim form.
The CMS 1500 Claim Form
The Center of Medicaid and Medicare Services (CMS) form 1500 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. To view instructions and a sample CMS 1500 with field descriptions, please see the below links:
The UB-04 Claim Form
The UB-04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities (for example, outpatient departments, rural health clinics, chronic dialysis, and adult day health care). To view instructions and a sample UB-04 with field descriptions, please see the below links:
Effective Medi-Cal Codes
The lined rate table below contains codes that are considered covered benefit for the Medi-Cal product line. This information is provided by the California Department of Health Care Services (DHCS) as information only for provider reference. While SFHP adopts most of the rate guidelines issues by DHCS, as a Managed Care Organization, SFHP may choose to deviate from these guidelines per SFHP company’s policies.
San Francisco Health Plan (SFHP) is preparing to implement a new managed care system that will feature a number of process enhancements and improve our ability to serve you.
SFHP Claims Matrix
| Patient’s Medical Network | Who processes claims? |
|---|---|
| AMG | Professional, Non-Emergency Transport: NMM Submit at networkmedicalmanagement.com Office Ally Payer ID: AAMG1 Mail claims to: 1600 Corporate Center Drive, Suite 106 Facility, DME, Emergency Transportation: CCHP Mail claims to: 445 Grant Ave, Suite 700 |
| BTP | Professional: Brown & Toland Phone 1(415) 972-6000 Mail claims to: Facility & DME: SFHP Mail claims to: |
| CLN | All claims: SFHP Phone 1(415) 547-7818 ext. 7115 Mail claims to: |
| HIL | Professional: Hill Physicians Phone 1(800) 445-5747 Mail claims to: Facility & DME: SFHP Mail claims to: |
| JAD | Professional, Non-Emergency Transportation: NMM Submit at networkmedicalmanagement.com Office Ally Payer ID: NMM07 Mail claims to: Facility, DME, Emergency Transportation: CCHP |
| NEM | All claims: NEMS MSO
Phone 1(415) 352-5186, Option 2 Fax 1(866) 930-2290 Mail claims to: |
| NMS (NEMS with SFHN) | All claims: NEMS MSO
Phone 1(415) 352-5186, Option 2 Fax 1(866) 930-2290 Mail claims to: |
| SDN (SFHP Direct Network) | If member has Medicare, bill Medicare first.
All other claims: SFHP Phone 1(415) 547-7818 ext. 7115 |
| SFN | All claims: SFHP Phone 1(415) 547-7818 ext. 7115 Mail claims to: |
| UCS | All claims: SFHP
Phone 1(415) 547-7818 ext. 7115 Mail claims to: |
Non-Specialty Mental Heath Benefit Managed by Carelon
| Patient’s Medical Network | Who processes claims? |
|---|---|
| All Networks | All claims: Carelon
Phone 1(855) 371-8117, Option # Mail claims to: |
Vision Benefit Managed by VSP
| Patient’s Medical Network | Who processes claims? |
|---|---|
| All Networks | All claims: VSP
Phone 1(800)742-6907, Option 3 Mail claims to: |