Dear SFHP Members: Congress was unable to reach an agreement on funding for Fiscal Year 2026, and the federal government was shut down on October 1, 2025. While we do not know how long the shutdown will last, SFHP will continue its operations as normal. You can still access the care you need. We are committed to ensuring your access to care is not interrupted. If you encounter any issues, please contact SFHP Customer Service at 1(415) 547 7800 or toll-free 1(800) 288 5555 (TTY users can dial 711). We’re open Monday through Friday, from 8:00am to 5:00pm.

1(415) 547-7800 Contact Us

Cost Avoidance and Post-Payment Recovery for Other Health Coverage

DHCS released APL 21-002, Cost Avoidance and Post-Payment Recovery for Other Health Coverage (OHC). Medi-Cal members must utilize their OHC for covered services prior to utilizing their Medi-Cal benefits. Managed Care Plans (MCPs) must include OHC information in their notification to the provider when a claim is denied due to the presence of OHC. SFHP is required to make sure providers are identifying and billing the OHC carrier as primary prior to seeking payment from Medi-Cal. MCPs must seek reimbursement for covered services for which the third party is liable.

Link to DHCS APL 21-002:
APL 21-002 (ca.gov)

Please review these documents for additional information on the APL policy, DMG requirements, OHC reporting guidelines, and FAQs. Please note, SFHP will continue to update this page with new documents as we receive guidance from DHCS.

OHC information is now available on paper remittance advice and SFHP’s Provider Portal.

The following information is displayed on paper remits when a claim is denied due to the presence of OHC:

  • Carrier Name
  • Member Policy Number
  • Carrier Phone Number
  • Carrier Address

For providers receiving electronic remittance advice (835s), SFHP’s Provider Portal has been enhanced to display the information.

APL 21-002 FAQs (3/17/2021)

APL 21-002 Appendix A – OHC Code Descriptions (3/17/2021)

SFHP – OHC Reporting Memo (4/8/2021)

DMG Requirements Memo (6/2/2021)

APL 21-002 Appendix B – Reporting Requirements (6/2/2021)

Carrier Code List (6/2/2021)

OHC Information Report Template (6/2/2021)

For further questions regarding APL 21-002, please contact SFHP’s Provider Relations Department at 1(415) 547-7818 ext. 7084  or email [email protected]

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