San Francisco Health Plan EDI Claims: Common Requirements

San Francisco Health Plan EDI ClaimsSan Francisco Health Plan EDI Claims are processed for the following medical groups: San Francisco Community Clinic Consortium, San Francisco Health Network (previously known as the Community Health Network) and UCSF Medical Group. Any delegated medical group must submit encounter EDI data to San Francisco Health Plan in lieu of EDI claims.

San Francisco Health Plan EDI Claims must be submitted electronically in a HIPAA 5010 837-compliant format. Providers may check EDI claim status as well as eligibility and authorization status through the Provider Portal. The Provider Portal can be accessed on San Francisco Health Plan website. EDI Claims denied or rejected for insufficient or incorrect claim data and/or for documentation, can be corrected and resubmitted for processing.

San Francisco Health Plan EDI Claims Timelines

SFHP complies with AB1455 timeline guidelines. SFHP shall reimburse each complete EDI claim, or portion thereof, whether in state or out of state, as soon as practical, but not later than 45 working days after the date of receipt of the complete claim, unless the complete claim or portion thereof is contested or denied. The receipt date used for claims processing on claims submitted through the mail is the actual date the claim was received at SFHP. Electronic claims submitted after 10:30 am are assigned to the following business day’s receipt date.

The original EDI claim should be billed to SFHP as soon as possible from the date of service. However, the original clean claim must be received at SFHP within 6 months of the date services were rendered to avoid a reduction in payment. After six months from the service date, there is a payment reduction as defined by Medi-Cal regulations. Claims received after 365 days from the Date of Service or the primary payer paid date will denied for timely filing. This requirement is referred to as the One-Year Billing Limit.

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