Non-Participating Provider Claim Information
Learn how non-participating providers can submit claims, access electronic data interchange (EDI) tools and receive support when working with Sutter Health Plan members.
Authorization for Post-Stabilization Care
To authorize post-stabilization care for emergency or urgent services, non-participating providers must call 855-315-5800 or TTY 855-830-3500.
Commercial HMO Claims Submission
Submitting Claims
Non-participating providers must submit out-of-area emergency and urgent care claims for Sutter Health Plan members to the following address:
Sutter Health Plan
P.O. Box 211553
Eagan, MN 55121
Non-participating providers must submit all other claims to the member’s participating provider group (PPG). You can find the PPG address and the claims submission address on the member’s ID card. Use the CMS 1500 form for professional claims and the UB 04 form for facility claims. Sutter Health Plan redirects misdirected claims to the correct address, which delays processing.
Claims Submission Support
For assistance with the member’s PPG or claims submission address, call Customer Service at 855-315-5800, Monday through Friday, 8:00 am – 7:00 pm.
Timely Filing of Claims
The claims receipt date is the business day Sutter Health Plan first receives the claim.
- Providers must submit claims within 180 calendar days from the date of service
- Sutter Health Plan acknowledges paper claims within 15 business days of receiving them
- Sutter Health Plan processes claims within 45 business days of receipt
Under the coordination of benefits (COB) rules, if Sutter Health Plan isn’t the primary payer, providers must submit claims within 90 days from the date the primary payer pays, contests or denies the claim. Claims submitted outside the applicable filing timeframe will be denied. However, if a claim is denied for late submission and the provider can demonstrate timely billing efforts, Sutter Health Plan may reconsider the claim.
Complete Claim Definition
A complete claim follows the format established by the National Uniform Billing Committee and includes all necessary attachments, supplemental information and documentation to determine payer liability. Incomplete claims may be denied.
Correct Coding
Providers must use valid diagnosis and procedure codes to ensure claims are accurate.
Diagnosis Codes
Use the International Classification of Diseases, Tenth Revision and Clinical Modification (ICD-10-CM) to code diagnostic information on claims. Code to the highest level of specificity (maximum number of digits).
Procedure Codes, Facility Claims
For facility claims, providers must use the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) and Revenue codes.
Procedure Codes, Professional Claims
For professional claims, providers must use the Current Procedural Terminology, Level I or Healthcare Common Procedure Coding System (HCPCS) Level I and II codes.
Provider Dispute Resolution Process
Non-participating providers must complete the Provider Dispute Resolution Request (PDR) form for claims processed by Sutter Health Plan. In cases involving claims processed by the PPG, non-participating providers must follow the PMG's claims dispute resolution process to address payment disputes or claim denials.
We offer a second-level dispute process for non-participating providers who are dissatisfied with the outcome of the PPG dispute resolution. Non-participating providers must complete the PDR form to initiate this process.
What you need to know:
- Providers must submit disputes to Sutter Health Plan within 365 days of the most recent claim decision.
- The dispute must include all required information for review.
- We acknowledge receipt of mailed PDRs within 15 business days.
- If we request additional information, submit amended disputes with the requested details within 30 business days.
Sutter Health Plan reviews disputes or amended disputes and provides a determination within 45 business days of receipt.
Electronic Transactions
Non-participating providers treating Sutter Health Plan members can streamline their workflows with electronic data interchange (EDI). EDI enables providers to check eligibility and benefits, review claims status updates and access electronic remittance advice (ERA).
Edifecs is acting as a connectivity proxy for Sutter Health Plan EDI transactions. Sutter Health Plan 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
- 835 electronic remittance advice
All responses comply with the Council for Affordable Quality Healthcare® — Committee on Operating Rules for Information Exchange® (CAQH CORE) Phase I, II and III certification requirements and HIPAA regulations.
How to Set Up EDI
To successfully submit EDI transactions, providers must use their existing clearinghouse or practice management system vendor to exchange information with Edifecs. Acting on behalf of Sutter Health Plan, Edifecs processes inquiries and returns eligibility, benefits, claims status updates and ERAs to the provider's clearinghouse or practice management system. Please note that Sutter Health Plan doesn’t endorse any specific clearinghouse.
To request access to the Edifecs application, providers must follow these steps:
- Step 1: Complete the Provider EDI Request form (PDF).
- Step 2: Email the completed form to Sutter Health Plan 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.
- Step 3: Edifecs will contact providers by telephone within seven business days of receiving the form to finalize the set-up process. Please note that Edifecs will ask providers to supply a username and password to establish connectivity to the application.
EDI Submission Support
Contact shpedi.support@sutterhealth.org for help with EDI form submissions or connection issues after becoming a trading partner.
EDI Companion Guides
The following companion guides describe specific technical details for EDI transactions.