CAQH CORE Compliant Electronic Transactions

San Francisco Health Plan is committed to providing our participating providers with the best tools possible to support their administrative needs. We are now providing electronic transactions that are compliant with the Council for Affordable Quality Health Care (CAQH) Committee on Operating Rules for Information Exchange (CORE) Operating Rules. San Francisco Health Plan is a Phase III CORE Certified Health Plan. Use our secure electronic transactions to save time and money.

Eligibility and Benefits Request and Response (270/271)

The 270 and 271 transactions are used in tandem: the 270 transaction is used to inquire about the eligibility benefit status of a subscriber, and the 271 transaction is returned in response to that inquiry. SFHP returns detailed eligibility, co-payment, deductible, co-insurance, and type of insurance information on the 271 response. SFHP provides the ability for a practitioner or facility to submit a file for eligibility information and benefits for our members (HIPAA Eligibility Benefits Inquiry and Response 270-271) through their designated clearinghouse or directly to their office as instructed. To establish a connection for the 270/271, please contact your clearinghouse in regard to setting up the ability to submit and receive the electronic eligibility and benefits inquiries with SFHP. If you currently are not utilizing a software vendor contact our EDI Team for alternatives: edi@sfhp.org.

The information in the following companion guide clarifies SFHP’s business and processing rules that are relevant to the implementation of the 270 and 271 transactions, version 5010. For more information, please send an email to edi@sfhp.org.

• SFHP Eligibility Inquiry and Response 270-271 Companion Guide

Health Care Claim and Encounter Submission (837)

The 837 transaction is used to submit medical claims for payment or medical encounter data to comply with contractual requirements.  The 837 Health Care Claim standard has three variations, Institutional, Professional, and Dental to provide for variations in types of services.  Hospitals and other in-patient facilities typically submit institutional 837s, PCPs and specialists usually submit professional 837s, and dental 837s are used only for dental services.  Please contact your clearinghouse in regard to setting up the ability to submit electronic health care claims and encounters to SFHP, or if you are currently not utilizing a software vendor, contact our EDI Team for alternatives: edi@sfhp.org.

The information in the following companion guides clarifies SFHP’s business and processing rules that are relevant to the implementation of 837 transactions, version 5010.  For more information, please send an email to edi@sfhp.org.

• Professional – SFHP 837P HIPAA 5010A1 Companion Guide
• Institutional – SFHP 837I HIPAA 5010A2 Companion Guide

Claim Status Request and Response (276/277)

The 276 and 277 transactions are used in tandem: the 276 transaction is used to inquire about the current status of a specified claim or claims, and the 277 transaction in a response to that inquiry. SFHP provides the ability for a practitioner or facility to submit a file for claim status for our members (HIPAA Eligibility Benefits Inquiry and Response 276-277) through their designated clearinghouse or directly to their office as instructed. To establish a connection for the 276/277, please contact your clearinghouse in regard to setting up the ability to submit and receive the electronic claim status inquiries with SFHP. If you currently are not utilizing a software vendor please contact our EDI Team for alternatives: edi@sfhp.org. The information in the following companion guide clarifies SFHP business and processing rules that are relevant to the implementation of the 276 and 277 transactions, version 5010. For more information, please send an email to edi@sfhp.org.

• SFHP Claim Status Inquiry and Response 276-277 Companion Guide

Electronic Remittance Advice (ERA)

The 835 Health Care Claim Payment/Advice provides detailed payment information about health care claims submitted to SFHP. The 835 transaction may be returned for Professional 837 Claim electronic submissions, as well as paper and electronic CMS 1500 and UB04 claims submissions.

SFHP provides the ability for a practitioner/facility to receive Electronic Remittance Advice (ERA) through their designated clearinghouse or directly to their office as instructed. To establish a connection for 835s, please contact your clearinghouse in regard to setting up the ability to submit and receive the electronic eligibility and benefits inquiries with SFHP. If you currently are not utilizing a software vendor contact our EDI Team for alternatives: edi@sfhp.org. The following companion guide provides information about the 835 Health Care Claim Payment/Advice transaction, Version 5010. To enroll for this transaction, please fill out the ERA enrollment form below and email it to EFT_835_Intake@sfhp.org .

• SFHP Electronic Remittance Advice (ERA) Enrollment Form
• SFHP Electronic Remittance Advice (ERA) 835 Companion Guide

Electronic Funds Transfer (EFT)

EFT is an easy and efficient way to ensure your SFHP payments are deposited directly into your bank account. EFT is secure, confidential and convenient, and there is no charge to use this service. In order to participate in EFT, your financial institution must be a participating member of the Automated Clearinghouse Association (ACH). You must contact your financial institution to arrange for the delivery of reassociation information via the ACH Cash Concentration or Disbursement (CCD) plus addenda record. It is the provider’s responsibility to notify SFHP of any changes to your banking information. Please allow 10-15 business days for processing. Processing times may vary. To enroll for EFT or for additional information, please contact the Finance Department at EFT_835_Intake@sfhp.org.

• SFHP Electronic Fund Transfer (EFT) Authorization Agreement