Non-Participating Provider Claim Information

Non-participating providers must submit out-of-area emergency and urgent care claims for Sutter Health Plus members to the following address:

Sutter Health Plus
P.O. Box 160385
Sacramento, CA 95816

Non-participating providers must submit all other claims to the member’s participating medical group (PMG). Sutter Health Plus includes the PMG and claims submission address on the member’s identification (ID) card. Providers can also call Sutter Health Plus Member Services at (855) 315-5800 for the member’s PMG and claims submission address. Member Services is available Monday through Friday, 8:00 am to 7:00 pm.

Providers must bill professional claims on the CMS 1500 form and facility claims on the UB 04 form. Sutter Health Plus will route any misdirected claims to the correct address. Redirecting will delay claims processing.

Provider must submit claims within 180 calendar days from the date of service.    

Sutter Health Plus acknowledges paper claims within 15 business days. The claims receipt date is the business day Sutter Health Plus first receives the claim.

Sutter Health Plus processes claims within 45 business days of receipt.

If we are not the primary payer under coordination of benefits (COB) rules, the claim submission period is within 90 days of the date the primary payer has paid, contested or denied the claim. Sutter Health Plus will deny claims not received within the applicable claim filing timeframe. If we deny a claim because it was not filed within the applicable claim filing timeframe, but the provider can demonstrate efforts to bill timely, we may reconsider the claim.

A complete claim is a claim, or portion of a claim that is submitted on a complete format adopted by the National Uniform Billing Committee and which includes attachments and supplemental information or documentation that provide reasonably relevant information or information necessary to determine payer liability. Incomplete claims are subject to denial.

Providers must use current valid diagnosis and procedure codes to ensure claims are as accurate as possible.

Diagnosis Codes

Use International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), to code diagnostic information on claims. Code to the highest level of specificity (maximum number of digits).

Procedure Codes

For facility claims, providers must use the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) and Revenue codes.

For professional claims, providers must use the Current Procedural Terminology, Level I or Healthcare Common Procedure Coding System (HCPCS) Level I and II codes.

For Sutter Health Plus-processed claims, non-participating providers must complete the Provider Dispute Resolution Request form and mail to the following address:

Sutter Health Plus
P.O. Box 160366
Sacramento, CA 95816

For PMG-processed claims, non-participating providers must follow the claims provider dispute resolution (PDR) process established by the PMG to contest the payment or denial of a claim.

Sutter Health Plus offers a second-level dispute process for non-participating providers dissatisfied with the dispute resolution from the PMG. For a second-level dispute of a PMG-processed claim, non-participating providers must complete the Provider Dispute Resolution Request form and mail to the following address:

Sutter Health Plus
P.O. Box 160366
Sacramento, CA 95816

Providers must submit a dispute to Sutter Health Plus within 365 days of the most recent determination or action for the claim, and must include specific information needed to complete the review of the dispute. We acknowledge receipt of PDRs sent by mail within 15 business days of the date we receive. Providers must submit an amended dispute that includes the missing information within 30 business days following receipt of the request for additional information.

Sutter Health Plus makes a determination and notifies the provider within 45 business days after the receipt of the dispute or the amended dispute.

Non-participating providers who treat Sutter Health Plus members can use electronic data interchange (EDI) to submit and receive responses to eligibility and benefit, and claims status inquiries. Using EDI allows providers to verify Sutter Health Plus member eligibility and benefit information, and check status of claims submissions, without picking up the telephone.

Edifecs is acting as a connectivity proxy for Sutter Health Plus eligibility and benefit, and claims status inquiries and responses.

Sutter Health Plus makes the following transactions available through Edifecs:

• 270 eligibility and benefit inquiry
• 271 eligibility and benefit inquiry response
• 276 claims status inquiry
• 277 claims status inquiry response

All responses are compliant with the Council for Affordable Quality Healthcare® – Committee on Operating Rules for Information Exchange® (CAQH CORE) Phase I and II certification requirements and with HIPAA regulations.

Getting Started

For successful EDI submission, providers must use their existing clearinghouse or practice management system vendor to exchange transactions with Edifecs. Edifecs receives inquiries on behalf of Sutter Health Plus and then returns eligibility, benefit, and claims status inquiries back to the provider’s clearinghouse or practice management system vendor. Sutter Health Plus does not endorse any clearinghouses.

To request access to the Edifecs application, providers must fill out the Provider EDI Request form and email the completed form to Sutter Health Plus at shpedi.support@sutterhealth.org. The information provided on the form allows Edifecs to set up providers as trading partners and recipients of electronic data. Edifecs will contact providers by telephone within seven business days of receipt of form to finalize the set up process. Please note: Edifecs will ask providers to supply a user name and password to establish connectivity to the application.

Providers who have questions regarding form completion can contact Sutter Health Plus at shpedi.support@sutterhealth.org. Providers who experience problems connecting after being set up as a trading partner can contact Sutter Health Plus at shpedi.support@sutterhealth.org.

EDI Companion Guides

The following companion guides describe specific technical details for EDI transactions.

• 270/271 HIPAA Transaction Standard Companion Guide (PDF)
• 276/277 HIPAA Transaction Standard Companion Guide (PDF)