Provider Alerts

This alert serves as a reminder to all Health Plan of San Joaquin (HPSJ) providers that balance billing Medi-Cal members is prohibited by federal and state law. Medi-Cal members should not pay for physician visits and other medical care when they receive covered services from any HPSJ provider. This means members cannot be charged for co-pays, co-insurance, or deductibles.

HPSJ providers cannot balance bill a member. Medi-Cal payment for covered services constitutes payment in full. If a member was invoiced or a charged in error, any billing efforts must cease as soon as the error is identified. If a member paid for covered services, the provider must refund the member within fifteen (15) days.

Billing Medi-Cal members violates Federal law as outlined in section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997. This section of the Act is available at: http://www.ssa.gov/OP_Home/ssact/title19/1902.htm.

Protections are also found in California Welfare and Institutions Code section 14019.4. HPSJ providers must adhere to appropriate billing practices and should not charge members. The Department of Health Care Services (DHC) reviews billing practices as a component of HPSJ’s Annual Medical Audit. Violation of billing practices may lead to enforcement actions.

For additional billing laws see, W&I Code section 14019.3; W&I Code section 14019.4; Title 28 CCR 1300.71; Title 22, §51002; Title 42 CFR section 447.15.

If you have questions or need assistance, please call our Provider Services team at (209) 942-6340. You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/.