Clean Claims EDI Processing and Other Health Coverage Cases
Clean Claims will be processed by San Francisco Health Plan as submitted in a timely manner for medically necessary and covered services by a participating provider group in accordance with the agreement between SFHP and the provider group for the applicable benefit program. Clean Claims are defined as fully completed claims containing all the required data necessary (including any essential documentation) for accurate adjudication.
Some San Francisco Health Plan members have other health coverage (OHC) in addition to their San Francisco Health Plan coverage. Specific rules govern how benefits must be coordinated in these cases. When a San Francisco Health Plan 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.
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.
- For CMS-1500 claims, please submit the Medicare Remittance Notice (MRN).
When a SFHP members’ primary insurance has co-payments and/or deductibles, the member cannot be asked to pay, as long as he or she is obtaining benefits within the rules of the primary insurance.