Compliance Program

As the local health plan of choice, the mission of the Health Plan of San Joaquin / Mountain Valley Health Plan (“Health Plan”) Compliance Program is to support our partners with respect, integrity and clarity. Our vision is to be a trusted partner in Compliance and Service. The program establishes and enforces compliance with ethical standards, Health Plan policies and procedures (P&P), contract requirements and applicable federal and state laws and regulations. To review our Compliance Program Plan, please click HERE.

Health Plan has established, implemented, and provides effective training and education for all network providers and their staff.

Report Compliance, Privacy or Fraud, Waste & Abuse Issues

Anyone can report concerns 24 hours a day, 7 days a week, including employees, members, providers, vendors, etc. Health Plan takes all allegations of non-compliance seriously and will maintain the confidentiality of all reports. All persons may report anonymously without fear of intimidation and/or retaliation.

Call: 1-855-400-6002 | Fax: 1-215-689-3885 | Email: reports@lighthouse-services.com | Website: www.lighthouse-services.com/hpsj
Mail: Health Plan of San Joaquin / Mountain Valley Health Plan
         Attn: Compliance Officer
         7751 S Manthey Rd
         French Camp, CA 95231

Compliance Policies
& Procedures

Fraud, Waste, & Abuse/
Privacy Policies & Procedures

Utilization
Management

Quality
Management


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Pharmacy Policies
& Procedures


Dec 19th, 2025 PH04 - Pharmacy Therapeutics Committee Aug 14th, 2025 PH05 Prior Authorizations - English Aug 14th, 2025 PH05 Prior Authorizations - English - LARGE PRINT Aug 14th, 2025 PH05 Prior Authorizations - Spanish Aug 14th, 2025 PH05 Prior Authorizations - Khmer Aug 14th, 2025 PH05 Prior Authorizations - Vietnamese Aug 14th, 2025 PH08 Managed Drug Limitations - English Aug 14th, 2025 PH09 Step Therapy - English Aug 14th, 2025 PH10 Dispensing of Off-Label Prescriptions - English Aug 14th, 2025 PH11 Therapeutic Interchange - English Aug 14th, 2025 PH14 Pharmaceutical Safe Use Monitoring of Physician Administered Drugs - English Aug 14th, 2025 PH17 Member Communication - English Aug 14th, 2025 PH18 Practitioner Communication - English Aug 14th, 2025 PH19 Nutritional Supplements for Medical Conditions - English Aug 14th, 2025 PH21 Drug Utilization Review - English Aug 14th, 2025 PH23 Submission of Pharmacy Benefit Prior Authorization & Claims - English Aug 14th, 2025 PH23 Submission of Pharmacy Benefit Prior Authorization & Claims - English - LARGE PRINT Aug 14th, 2025 PH23 Submission of Pharmacy Benefit Prior Authorization & Claims - Spanish Aug 14th, 2025 PH23 Submission of Pharmacy Benefit Prior Authorization & Claims - Khmer Aug 14th, 2025 PH23 Submission of Pharmacy Benefit Prior Authorization & Claims - Vietnamese Aug 14th, 2025 PH25 Pain Medication Requests for the Terminally Ill - English Aug 14th, 2025 PH30 Medical vs. Pharmacy Benefit - English Aug 14th, 2025 PH30 Medical vs. Pharmacy Benefit - English - LARGE PRINT Aug 14th, 2025 PH30 Medical vs. Pharmacy Benefit - Spanish Aug 14th, 2025 PH30 Medical vs. Pharmacy Benefit - Khmer Aug 14th, 2025 PH30 Medical vs. Pharmacy Benefit - Vietnamese Aug 14th, 2025 PH32-Non-Opioid-Pain-Management - English Aug 14th, 2025 PH32-Non-Opioid-Pain-Management - Spanish Aug 14th, 2025 PH33 Pharmacy Services - English - LARGE PRINT Aug 14th, 2025 PH33 Pharmacy Services - Spanish Aug 14th, 2025 PH33 Pharmacy Services - Khmer Aug 14th, 2025 PH33 Pharmacy Services - Vietnamese
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Medication
Coverage Policies


Dermatologic Disorders

Endocrine Disorders


Gastrointestinal Disorders


Immunology


Infectious Disease


Miscellaneous


Neurological Disorders


Oncology


Ophthalmic Disorders


Renal Disease/Genitourinary Disorders


Respiratory Disorders


Rheumatologic/Immunologic Disorders


Posted on December 19th, 2025 and last modified on December 24th, 2025.

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