How a claim is built

The rules this tool applies, which are the rules in the warehouse’s dbt models as documented by the Data Team in September 2026. Where the rules have a known gap, the tool reproduces the gap and flags it as an extra check.

1 · Which shipments are billed

The plan code decides the file: ABC/ABCD → Anthem, CCAH/CCAHD → CCAH, CHPIV, IEHP, KFHC → Kern, SCFHP/SCFHPD → SCFHP. Any other code goes to no file.
Nutrition counselling (NC) is billed when its status is Completed. Every other product is billed when its status is delivered. Codes match exactly, including letter case.
Anthem only: the authorization number must start with UM. Rows that don't are left out - dbt never reports them; this tool does.
There is no date cut-off and no deduplication: every row that passes becomes exactly one claim.

2 · Dates of service

NC: from and to are both the delivery date.
MTM, MSF, MSG: from is the Monday of the delivery week, to is the Sunday after it.
Both signature dates on the claim are set to the from date.

3 · Diagnoses

Diagnosis 1 empty → R69 (illness, unspecified). Diagnoses 2 and 3 still go through on their own.
Diagnosis 1 unbillable (starts with XXX, or is Z33.1, Z33.41 or Z59.41) → Diagnosis 2 becomes the primary, as-is; Diagnoses 2 and 3 on the claim are emptied. Diagnosis 3 is never promoted.
Otherwise Diagnosis 1 passes through unchanged, with its decimal part. Diagnoses 2 and 3 pass through unless empty or XXX-prefixed.
The pointer is A, AB or ABC depending on how many diagnoses ended up on the claim.

4 · Codes, units, place of service

MTM → S5170 (Medically tailored meals (MTM)), 14 units. MSF and MSG → S9977 (Medically supportive food (MSF / MSG)), 1 unit. NC → S9470 (Nutrition counselling (NC)), 1 unit. Anything else → no code, flagged Review.
The raw procedure code in the file is ignored since 2026-08: it can be missing; the product type cannot.
Place of service is 2 (telehealth) with modifier GQ for NC; 12 (home) for everything else. Modifier U6 is always set.

5 · Charge

The contracted rate for the plan and code, from the rate table. Anthem's rate depends on the member's county.
No rate on file → the charge is empty and the claim is flagged Review. The row stays in the file.
Charges1, TotalCharges and BalanceDue are always the same number. PatientID and PatientAcctNumber are always the same value.

6 · RecordStatus

Review when: the product type has no code; or there is no rate on file; or Diagnosis 1 is empty/unbillable and Diagnosis 2 is empty too.
Everything else is Correct. Nothing is removed from the file either way.

7 · The six plans

Plan	Codes	Payer ID	Remit to	Particulars
Anthem Blue Cross	ABC, ABCD	47198	PO Box 60007 Los Angeles, CA, 90060-0007 Los Angeles, CA, 90060-0007	Only shipments whose authorization number starts with UM are billed. Anything else is dropped before the claim file - this tool lists those rows so nothing disappears silently. PatientID is the CIN with a prefix: JQC when the CIN starts with 9 and the county is Los Angeles, XDJ when it starts with 9 elsewhere, MNL otherwise (unless already MNL). The contracted rate depends on the member's county. A county with no rate on file produces a Review claim with no charge.
Central California Alliance for Health	CCAH, CCAHD	CCA01	PO BOX 660015 SCOTTS VALLEY, CA, 95067-660015	ToDateOfService1 is left empty for weekly claims (S9977 and S5170) and only filled for nutrition counselling (S9470). No other payer does this - open question for Billing.
Community Health Plan of Imperial Valley	CHPIV	66170	PO Box 210100 Chula Vista, CA, 91921	No contracted rate on file for S9470 (nutrition counselling): every NC claim is flagged Review.
Inland Empire Health Plan	IEHP	IEHP1	PO BOX 4349 Rancho Cucamonga, CA, 91729-4349	—
Kern Health Systems	KFHC	77039	P.O. Box 85000 Bakersfield, CA, 93380-9998	InsuranceZip says 93880-9998 but InsuranceCityStateZip says 93380-9998. One of the two is a typo; both are reproduced as-is until Billing confirms the right one.
Santa Clara Family Health Plan	SCFHP, SCFHPD	24077	P.O. Box 18640 San Jose, CA, 95158-18640	No contracted rate on file for S9470 (nutrition counselling): every NC claim is flagged Review.

Provider side on every claim: Project Food Box · Tax ID 330932223 · NPI 1619624616 · 892 W 18th st., Costa Mesa, CA 92627 · supplier Sunterra Health.

Open questions for Billing and Finance

Until these are answered the tool does exactly what the warehouse does today.

Kern's payer ZIP: InsuranceZip says 93880-9998, InsuranceCityStateZip says 93380-9998. Which is right?
Should Z33.1, Z33.41, or both, count as unbillable primary diagnoses?
CHPIV and SCFHP have no rate for S9470. Pending from Finance, or intentionally not billed?
CCAH leaves ToDateOfService1 empty for weekly codes. Should the other five plans do the same, or should CCAH stop?
Service lines 2-6 are always empty in the SQL although the documentation says otherwise. Placeholder for good?
When Diagnosis 1 is unbillable and Diagnosis 2 is a placeholder too, the claim goes out marked Correct with a placeholder as its primary diagnosis. Should that always be Review?
Rows Anthem drops for a non-UM authorization are invisible today. Should they appear somewhere (this tool lists them)?
SupplierState is 'Ca' and SupplierCityStateZip is 'Costa mesa, CA 92627' - both reproduced as-is. Tidy them, or does the clearinghouse not care?