Provider Alerts

A treating provider can request a peer-to-peer discussion with Health Plan’s medical director within 5 business days of receiving notification of a denied authorization.

1. A peer-to-peer discussion should only be sought upon the request of the ordering/admitting physician, or physician advisor, that is involved and familiar with the member’s care, though support staff may assist with scheduling.
2. To schedule the call for a prior authorization denial, contact Health Plan’s Utilization Management staff at 209-942-6353.
   a. Please be prepared to provide the following information:

• Name of the physician requesting the peer review
• Best available phone number and time to return call
• Member name and Health Plan ID number
• Authorization/Certification number

3. For denials of an inpatient stay, contact the nurse case manager assigned to your facility or 209-942-6353.
a. Please be prepared to provide the following information:

• Name of the physician requesting the peer review
• Best available phone number and time to return call
• Member name and Health Plan ID number
• Tracking/referral number

b. The requester must attest/confirm that they are familiar with the case and either have specific questions about the criteria used to make the decision or have new information regarding the case that may lead to a change in decision.

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