Claims

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.

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 Monterey Park, CA 91754 Facility, DME, Emergency Transportation: CCHP provider.services@cchphealthplan.com Phone 1(415) 955-8800 Fax 1(415) 955-8812 Mail claims to: 445 Grant Ave, Suite 700 San Francisco, CA 94108
BTP	Professional: Brown & Toland Phone 1(415) 972-6000 Mail claims to: PO Box 72710, Oakland, CA 94612- 8910 Facility & DME: SFHP Phone 1(415) 547-7818 ext. 7115 Mail claims to: P.O. Box 194247, San Francisco, CA 94119
CLN	All claims: SFHP Phone 1(415) 547-7818 ext. 7115 Mail claims to: P.O. Box 194247 San Francisco, CA 94119
HIL	Professional: Hill Physicians Phone 1(800) 445-5747 Mail claims to: PO Box 8001 Park Ridge, IL 60068 Facility & DME: SFHP Phone 1(415) 547-7818 ext. 7115 Mail claims to: PO Box 194247 San Francisco, CA 94119
JAD	Professional, Non-Emergency Transportation: NMM Submit at networkmedicalmanagement.com Office Ally Payer ID: NMM07 Mail claims to: 1600 Corporate Center Drive, Suite 106 Monterey Park, CA 91754 Facility, DME, Emergency Transportation: CCHP provider.services@cchphealthplan.com Phone 1(415) 955-8800 Fax 1(415) 955-8812 Mail claims to: 445 Grant Ave, Suite 700 San Francisco, CA 94108
KSR	All claims: Kaiser Member Services 1(800) 390-3510 Mail claims to: 2425 Geary Blvd San Francisco, CA 94115
NEM	All claims: NEMS MSO Phone 1(415) 352-5186, Option 2 Fax 1(866) 930-2290 Mail claims to: 2171 Junipero Serra Boulevard Suite 600 Daly City, CA 94014
NMS (NEMS with SFHN)	All claims: NEMS MSO Phone 1(415) 352-5186, Option 2 Fax 1(866) 930-2290 Mail claims to: 2171 Junipero Serra Boulevard Suite 600 Daly City, CA 94014
SDN (SFHP Direct Network)	If member has Medicare, bill Medicare first. All other claims: SFHP Phone 1(415) 547-7818 ext. 7115 Mail Claims to: P.O. Box 194247 San Francisco, CA 94119
SFN	All claims: SFHP Phone 1(415) 547-7818 ext. 7115 Mail claims to: P.O. Box 194247 San Francisco, CA 94119
UCS	All claims: SFHP Phone 1(415) 547-7818 ext. 7115 Mail claims to: P.O. Box 194247 San Francisco, CA 94119

Non-Specialty Mental Heath Benefit Managed by Carelon

Patient’s Medical Network	Who processes claims?
All Networks except Kaiser	All claims: Carelon Phone 1(855) 371-8117, Option # Mail claims to: 5665 Plaza Drive, Suite 400, Cypress, CA 90630

Vision Benefit Managed by VSP

Patient’s Medical Network	Who processes claims?
All Networks except Kaiser	All claims: VSP Phone 1(800)742-6907, Option 3 Mail claims to: P.O Box 385018 Birmingham, Alabama 35238-5018