Provider Alerts

As part of Health Plan of San Joaquin’s (HPSJ) continued efforts to ensure each Provider Dispute Resolution (PDR) is appropriately routed for review, as of April 15, 2021, HPSJ will implement several new enhancements to the PDR process.

HPSJ asks that you continue to follow the following procedures.

• Contracted Providers must submit a provider dispute online through the
  Provider Portal/Doctors Referral Express (DRE) https://provider.hpsj.com/dre/default.aspx.
• Non-Contracted Providers must mail-in provider disputes with the appropriate HPSJ Provider Dispute Resolution (PDR) form (https://www.hpsj.com/provider-dispute-resolution/) to –
  Attention: Claims Department
  Health Plan of San Joaquin
  P.O. Box 30490
  Stockton, CA 95213-30490
• If you are submitting corrections on a claim, please follow the Corrected Claim submission guidelines.
• If a claim was denied as a duplicate and you feel it denied in error – before you submit a dispute – please make sure it was submitted with the appropriate documentation, modifiers, or corrected claim submission indicator.
• If a claim or claim line was denied for “supporting documentation” please submit as Correspondence with the requested information.

Reason(s) for PDR (Provider Dispute Resolution) Request:

• Contract Dispute: Original claim did not pay per contracted or MCL rate
• Appeal of Medical Necessity/Utilization Management Decision: Original claim denied because of a denied authorization or partial authorization
• Seeking Resolution of a Billing Determination: Do not agree with a claim or claim line denial
• Recovery Dispute: A letter was received regarding an identified overpayment and you do not agree with the determination
  • If the provider wishes to contest (Recovery Request Dispute) the notice of reimbursement of overpayment request it must be within thirty (30) working days.
• Seeking Resolution of a Supplemental Payment: Do not agree with the amount supplemental and/or denial of the supplemental payment

What is changing or new in the PDR process

1. Revisions have been made to the PDR form to make it easier for providers to use.
2. All provider appeals must be submitted with a completed PDR Form.
3. Providers should not submit a PDR for claims that have been rejected due to billing errors. Providers should submit a corrected claim for these circumstances. Click here (Provider Alert, April 22, 2016) for corrected claim submission.
4. Using the PDR form enables us to properly route your request, along with all
   supporting documentation, to the appropriate area for review.
5. Submissions must include the most appropriate supporting documentation. Examples include notes (surgical/operative/office); pathology reports; medical invoices (e.g., DME or pharmaceuticals); medical record entries; etc.
6. A PDR form that is not completed correctly will be returned as incomplete.
7. Provider/Facility may only submit a total of three (3) PDRs per claim number.
8. Contracted Providers must submit Correspondence online through the
   Provider Portal/Doctors Referral Express (DRE).
9. Non-Contracted Providers must mail in Correspondence to the attention of
   the Claims Department (Health Plan of San Joaquin, P.O. Box 30490, Stockton, CA 95213-30490), with the claim Remittance Advice identifying claim number and reason for additional documentation submission.

If you have questions, please contact our Customer Service Department at 209-942-6320.