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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

Resources

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 specifics 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:

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

Submit all non-delegated claims to SCFHP (see SCFHP claims billing)

Palo Alto Medical Foundation

​Submit all Medi-Cal claims to SCFHP (see SCFHP claims billing​)

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.

Emergency physicians services, child health and disability prevention (CHDP), durable medical equipment (DME), hearing aids, home health, inpatient and outpatient facility, inpatient pathology, and injectables over $250 are non-delegated claims and are the responsibility of SCFHP.

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.

CHDP, DME, hearing aids, home health, inpatient and outpatient facility, and injectables over $250 are non-delegated claims and are the responsibility of SCFHP.

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):

Delegated for all professional and facility claims.

Non-medical transportation (NMT) and non-emergency medical transportation (NEMT), and CBAS are non-delegated claims and are the responsibility of SCFHP. ​

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

Submit all non-delegated claims to SCFHP (see SCFHP claims billing)

SCFHP claims billing

Effective May 18, 2020, most Medicare dual crossover claims will be submitted through a Coordination of Benefits Agreement (COBA) with the Centers for Medicare & Medicaid Services (CMS). This means that you will not need to submit most claims for members with Medicare Fee-for-Service and Medi-Cal through SCFHP. Please refer to the provider memo: New billing process for Medicare crossover claims through COBA for additional information.

SCFHP does not accept claims or provider disputes (PDR) via FAX.

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.

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.

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 must include all services rendered and listed on the original claim, not just the corrected information.

Corrected claims may be sent to SCFHP through a clearinghouse for claims processing. Be sure to indicate it's a corrected claim using frequency code 7, and reference the claim number it's correcting.

Submitting a corrected claim is not considered a dispute or an appeal. Submitting a corrected claim as a dispute or appeal may delay the claim process.

Dispute an SCFHP claim

Medi-Cal:

If you disagree with the claim's outcome, you may submit a dispute within 365 calendar days from SCFHP's remittance advice.

SCFHP will investigate your dispute and issue a written resolution within 62 calendar days or 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 SCFHP'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.