User Manual Q&AAnswer
Apr 12, 2025 - 04:24 AM
To submit a claim for ECM services, you will need to follow the billing guidelines provided by Santa Clara Family Health Plan (SCFHP). Here are the steps to submit a claim:
1. Prepare the necessary information: Make sure you have the member's identification information (name, date of birth, Medi-Cal Client Identification Number), rendering provider information, billing provider information, diagnosis code, date of service, place of service, procedure code, and modifiers.
2. Use the standard format: Submit the claim using the 837 Professional (837P) claim format. This is the standard format used by healthcare professionals and suppliers to transmit healthcare claims electronically.
3. Submit through a clearinghouse: Claims should be submitted through a clearinghouse that has a contractual relationship with SCFHP. The approved clearinghouses are Change HealthCare and OfficeAlly. Use payor ID 24077 when submitting claims.
4. Include the minimum required fields: The 837P claim should include the following minimum required fields: member identification information, rendering provider, billing provider, diagnosis code, date of service, place of service, procedure code, modifiers, and units of service.
5. Follow the billing table: Refer to the billing table provided in the ECM Billing Guide for the appropriate HCPCS codes, modifiers, and population modifiers to use for each type of ECM service.
6. Submit the claim with correct modifiers: Each claim should have one service modifier and one population modifier. The service modifiers for ECM services are U1, U1-GQ, U2, and U2-GQ. The population modifiers vary based on the population of focus (POF) and are listed in the billing table.
7. Bill for all services provided: Providers are required to bill for all services provided for each month, even if some services are paid $0. Make sure to include all eligible services in your claim submission.
8. Monitor claim status: You can check the status of your claims and retrieve remittance advice through the Payspan payment system or the SCFHP Provider Portal. Payspan is the new payment system used by SCFHP, and you can register for it to access payment details and receive electronic payments. The Provider Portal allows you to check claim status and perform other administrative tasks.
Please refer to the Santa Clara Family Health Plan Enhanced Care Management User Guide and ECM Billing Guide for more detailed information and specific instructions on claim submission.
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