Provider Alerts

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Date:	March 23, 2021
To:	Health Plan of San Joaquin (HPSJ) All Providers & Facilities
From:	Health Plan of San Joaquin
Subject:	DHCS Encounter Requirements – Date Validation
Business:	Medi-Cal Managed Care

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HPSJ has implemented several new claim denials if claims are not submitted with the required information. This is part of Health Plan of San Joaquin’s (HPSJ) continuing efforts to ensure each claim submission will reconcile with each encounter submission to the California Department of Health Care Services (DHCS).

Please review the following:

1. From Service/Statement Date must be less than or equal to Received Date (Claim Submission Date)
2. COB Paid Date must be greater than or equal to TO Service/Statement Date
3. COB Paid Date must be less than or equal to Received Date (Claim Submission Date)
4. Admission Date is required for inpatient encounters (both institutional and professional claims)
5. Admission Date must be less than or equal to From Statement Date*
6. Admission Date must be less than or equal to To Statement Date
7. Death Date must be greater than or equal to To Service Date
8. Discharge Date must be greater than or equal to To Service Date
9. Procedure Date must be greater than or equal to From Statement Date* (institutional claims)
10. Procedure Date must be less than or equal to To Statement Date (institutional claims)
11. From Service/Statement Date must be less than or equal to To Service/Statement Date
12. To Statement, Date must be less than or equal to Received Date (Claim Submission Date) (institutional claims)
13. To Service Date must be less than or equal to Adjudication Date (Claim processing date)
14. Date of Service must be greater than or equal to From Service Date (Professional claims)
15. Date of Service must be less than or equal to To Service Date (Professional claims)
16. Date of Service must be less than or equal to Adjudication Date (Claim processing date) (Professional claims)
17. Date Prescription Written must be less than or equal to Date of Service (Professional claims)

If a denial is received, a resubmission of the claim with the corrected/additional information is required using the Corrected Claim Process.

*#5 & #9: An issue was identified where the system was denying claims erroneously when billing emergency department or procedures one day prior for inpatient claims. The system has been corrected and claims will be adjusted within 30 business days of this notice. Please do not submit corrected claims or Provider Disputes/Appeals.

If you have questions, please contact our Customer Service Department at 209-942-6320.