Non-Participating Provider Claim Information

Submit claims for SHP members within 180 calendar days from the date of service. Facility claims must be billed on the UB-04 form. Professional claims must be billed on the CMS-1500 form. Claims submitted to the incorrect address will be routed to the correct address; however, redirecting will delay claim processing.

Out-of-Area Emergency and Urgent Care Claims

Submit out-of-area emergency and urgent care claims to the following address:

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

All Other Claims

Submit all other claims for SHP members to the member’s assigned participating medical group (PMG). See the SHP member identification card for the assigned PMG and the claim submission address or call Sutter Health Plus Member Services weekdays, 8:00 am – 7:00 pm at (855) 315-5800 or TTY: (855) 830-3500.

SHP considers claims from providers for services rendered to SHP members if claims are submitted within 180 calendar days from the date of service.

SHP acknowledges paper claims within 15 business days and electronic claims within two business days. The claims receipt date is the business day SHP or the clearinghouse first receive the claim.

SHP processes claims within 45 business days of receipt.

If SHP is 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. Claims not received within the applicable claim filing time frame are denied.

If a claim is denied because it was not filed within the applicable claim filing time frame, but the provider can demonstrate efforts to bill timely, SHP may reconsider the claim as if it had been submitted within the applicable claim filing time frame.

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.

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, bill on the UB-04 form using the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) and Revenue codes.

For professional claims, bill on the CMS-1500 form using the Current Procedural Terminology, Level I or Healthcare Common Procedure Coding System (HCPCS) Level I and II codes.

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.

SHP offers a second-level dispute process for 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 SHP 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. SHP acknowledges receipt of PDRs sent by mail within 15 business days of the date of receipt by SHP. Providers must submit an amended dispute that includes the missing information within 30 business days following receipt of the request for additional information. SHP makes a determination and notifies the provider within 45 business days after the receipt of the dispute or the amended dispute.