Provider Alerts

Medicare/Medi-Cal (Dual) HPSJ Members & Long-Term Care

Claims for Medicare/Medi-Cal recipients must first be billed to the appropriate Medicare carrier or intermediary for processing of Medicare benefits. Medi-Cal recipients may have Medicare eligibility if they are aged 65 years or older, blind, or disabled, or if the Medi-Cal eligibility verification system indicates Medicare coverage. If Medicare approves the claim, it must then be billed to HPSJ for coordination of benefits.

Providers should submit a claim directly to HPSJ if the following apply:

• The services are not covered by Medicare
• Medicare benefits have been exhausted
• Medicare has denied the claim, or the recipient is not eligible for Medicare

In a recent internal audit, HPSJ identified potential payments for ancillary services for Members in a skilled nursing facility with Medicare Part B coverage. For members that have both Medicare Part A & B, when members are no longer covered by Medicare Part A benefits in a Skilled Nursing Facility (SNF), providers are required to continue to submit Part B claims to Medicare for payment of ancillary services. In efforts to reconcile potential overpayments, HPSJ will be distributing Recovery Requests to individual LTC facilities in which payments were made for ancillary services when the member has Medicare Part B coverage. Any identified overpayments are required to be returned within thirty (30) working days. If you wish to contest an overpayment notice, please reference the recovery letter and Section 10: Claims Submission: Claim Overpayment for additional information on how to contest.

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If you have any questions or concerns about these changes, 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/.