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Submit a claim or dispute

Welcome to the Santa Clara Family Health Plan (SCFHP) Provider Resources page for claims. This page provides resources and instructions on:

  • Submitting claims to SCFHP
  • What to do if you disagree with the amount you were paid on a claim
  • Delegated claims arrangements

Submit a provider dispute online

Frequently asked questions

General information

SCFHP's two lines of business are:

  • Medi-Cal
  • Cal MediConnect

The line of business is identified on the member's SCFHP ID Card as shown below:

Sample ID card with Medi-Cal circled at top right

Claims delegation

Cal MediConnect

SCFHP does not delegate claims payment for Cal MediConnect. Please refer to the instructions in the Claims Billing section on this page for details about how to submit claims directly to SCFHP.

Medi-Cal

For Medi-Cal members, SCFHP has a number of delegated relationships with its provider network. Each agreement has unique characteristics that affect how and where you submit claims. The information below can assist you in submitting claims to the correct location, which will alleviate the need for SCFHP or our delegates to redirect a claim that was received at the incorrect location.

You may find the information to identify a delegated provider agreement below by delegate:

Kaiser:

Delegated for all professional and facility claims except for Community-Based Adult Services (CBAS) and Long-Term Care (LTC). 

Medi-Cal Claims:

Electronic claim submission:

Clearinghouse Payor ID
Change Healthcare 94135
Office Ally 94135
Relay Health RH009 
SSI NKAISERCA

Paper claim submission:

Kaiser Foundation Health Plan
Attn: Claims Administration Dept.
PO Box 12923
Oakland, CA  94604-2923

Physicians Medical Group of San Jose (PMG):

Delegated for In-Area Professional Claims (services within Santa Clara, Santa Cruz, Alameda, and San Mateo counties) and all family planning services.

SCFHP is responsible for Emergency Physicians services, Child Health and Disability Prevention (CHDP), Durable Medical Equipment (DME), hearing aids, home health, inpatient pathology, and injectables over $250. 

Submit delegated claims to:

Electronic claim submission – PMG accepts electronic claims through the following clearinghouses:

Clearinghouse Payor ID
ENS PMGSJ
Proxymed PMGSJ 
Office Ally EXC01
WebMD EXC01
Change Healthcare EXC01

Paper claim submission:

Excel MSO, Physicians Medical Group
P.O. Box 1997
San Leandro, CA 94577-1997

Submit all facility and non-delegated claims to SCFHP (see SCFHP Claims Billing)

Premier Care of Northern California: 

Delegated for In-Area Professional Claims (services within Santa Clara, Santa Cruz, Alameda, San Mateo and/or San Benito Counties) and all family planning services. 

SCFHP is responsible for CHDP, DME, hearing aids, home health, and injectables over $250. 

Submit delegated claims to:

Electronic claim submission:    

Clearinghouse Payor ID
Change Healthcare 95339
Office Ally CAPMN
MDX CAPMN

Paper claim submission:

Conifer Health Solutions
PO Box 261040
Encino, CA 91426

Submit all facility and non-delegated claims to SCFHP (see SCFHP Claims Billing)

Valley Health Plan (VHP):

Submit delegated claims to:

Electronic claim submission:

Clearinghouse Payor ID
Utah Health Information Network VHP01
Office Ally VHP02

Paper claim submission:

Valley Health Plan
PO Box 28407
San Jose, CA 95159

SCFHP claims billing

All claims submitted to SCFHP must be sent electronically through a clearinghouse that has a contractual relationship with SCFHP's clearinghouses (Change HealthCare and OfficeAlly) using payor ID 24077, in  HIPAA standard ASC X12N 837 (005010X222) Professional and ASC X12N 837 (005010X223) Institutional transactions, unless otherwise agreed upon by the parties.  Claims shall contain valid ICD, revenue, CPT, HCPCS codes, and other required codes as applicable.

In order to expedite claims payments, all claims may be sent through a clearinghouse. We use Office Ally and Change Healthcare. The SCFHP Payor ID is 24077.  You may also submit electronic claims to SCFHP using the Office Ally website.  

If you are unable to send electronically, you may submit paper claims to SCFHP at the address below:

SCFHP
PO Box 18640
San Jose, CA 95158

Timely filing deadline

SCFHP requires claims to be submitted within one year of the date of service. SCFHP may deny a claim that is submitted beyond the claim filing deadline.

Secondary claims may be submitted within one year of the primary payor's EOB date. Primary payor COB information may be submitted electronically on HIPAA standard ASC X12N 837 (005010X222) Professional and ASC X12N 837 (005010X223) Institutional transactions.

Reminder about illegal balance billing

A report by the federal Centers for Medicare and Medicaid Services (CMS) verifies a troubling trend that continues to be a concern for CMS: healthcare providers are illegally billing low-income Medi-Cal and Medicare beneficiaries. Balance billing occurs when doctors or hospitals charge patients with both Medicare and Medi-Cal for covered services. Charges are usually in the form of co-pays, co-insurance, or deductibles.

Patients who have both Medi-Cal and Medicare (including Medicare Advantage) should never be charged for services covered under Medi-Cal or Medicare. Balance billing is illegal under both federal and state law.

As more and more patients move to managed care plans, balance billing may increase due to doctor and hospital confusion. Please ensure that you and your staff are aware of the current balance billing law and policies regarding dual Medi-Cal and Medicare beneficiaries. For more information, see the resources below:

If you have any questions, please call our Customer Service Department at 1-408-874-1788.

Submitting a corrected claim

A corrected claim is where you identified missing information or misinformation on your original claims submission that resulted in a payment different than what you expected to receive.

Corrected claims may be sent to SCFHP through a clearinghouse for claims processing. Be sure to indicate it's a corrected claim, and reference the claim number it's correcting. Submitting a corrected claim as a dispute or an appeal will not expedite the claims processing.

Dispute an SCFHP claim

Medi-Cal/Healthy Kids:

If you disagree with the claim's outcome, you may submit a dispute within 365 calendar days from Santa Clara Family Health Plan's remittance advice.

SCFHP will investigate your dispute and issue a written resolution within 45 working days from the date the dispute is received.

Cal MediConnect:

If you disagree with the claim's outcome, you may submit a dispute within 120 calendar days from Santa Clara Family Health Plan's remittance advice.

SCFHP will investigate your dispute and issue a written resolution within 60 calendar days for contracted provider and 30 calendar days for non-contracted provider from the date the dispute is received. 

To submit a dispute, please use our dispute form.

Provider memos

Visit our Provider memos page for more details on claims and billing.