Provider Alerts

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To:	Health Plan of San Joaquin Providers
From:	Provider Services Department
Subject:	Document Requirements for Oxygen/Respiratory Equipment
Business:	Medi-Cal, AIM (now known as Medi-Cal Access Program)

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Effective December 15, 2015

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We at HPSJ, in collaboration with our network providers, want to ensure that your patients who require home oxygen – either as a new request or a request to continue using the oxygen – receive the oxygen and other associated supplies without a delay or interruption in service.

To assist us in establishing the medical necessity, and so we can authorize the oxygen requests expeditiously, please provide the following information with every request:

1. The diagnoses for which supplemental oxygen is being requested
2. Certificate of Medical Necessity for Oxygen, or equivalent information
3. The flow rate of oxygen prescribed
4. An estimate of the frequency (hours per day) and duration of use (months)
5. A recent oxygen saturation by pulse oximetry or ABG on room air and in a
   steady state within the preceding 30 days of the request

Note: A prescription for “OXYGEN PRN” or “OXYGEN AS NEEDED” is not acceptable.

Failure to provide all required documentation may result in delay of the delivery of the oxygen therapy.We appreciate your partnership in ensuring the best care for HPSJ’s members who are your patients. If you have any further questions, please contact our Provider Services Department at (209) 942-6340.