Provider Alerts

On April 15, 2021, Health Plan implemented several new enhancements to the PDR process. This alert serves as a reminder to ensure each Provider Dispute Resolution (PDR) is appropriately routed for review.

Health Plan asks that you continue to follow the procedures below:

• 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 Health Plan 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.

Note: Failure to submit the provider dispute through DRE, or on the Health Plan PDR form, will be returned for completion. This may result in a delay of processing and potentially could fall outside of the dispute processing guidelines set by the California Department of Managed Health Care (DMHC).

Reasons for a PDR Request:

• Contract Dispute: Original claim did not pay per contracted or Medi-Cal 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 supplemental amount and/or denial of the supplemental payment

PDR Process Reminders:

1. All provider appeals must be submitted with a completed PDR Form.
2. 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, https://www.hpsj.com/advice-correcting-cms-1500-claims-submissions-also-when-not-to-submit-a-dispute/ (Provider Alert, April 22, 2016) for corrected claim submission.
3. Using the PDR form enables us to properly route your request, along with all supporting documentation, to the appropriate area for review.
4. 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.
5. A PDR form that is not completed correctly will be returned as incomplete.

Provider/Facility may only submit a total of three (3) PDRs per claim number.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG