Provider Alerts

As you know, Health Plan launched a Medicare Advantage Dual Special Needs Plan (D-SNP) starting 01/01/2026 known as Health Plan of San Joaquin/Mountain Valley Health Plan Advantage D-SNP (HMO). This new plan serves members who are eligible for both Medicare and Medi-Cal, known also as Medi-Medi members. Under this structure, Medicare D-SNP is the primary payer, while Medi-Cal is secondary, or payer of last resort.

Medi-Medi members enrolled with HPSJ/MVHP for both Medicare and Medi-Cal, payments consist of two processed claims with two distinct claims numbers. There are two different claim numbers for each claim submitted.

• First, the claim is processed under the D-SNP line of business as the primary claim. This claim number includes an “E” in the numbering sequence.
• Then, it processes under the Medi-Cal line of business as a secondary claim. A new claim number with a different numbering sequence is generated without the “E”.
• Per regulatory guidelines, members must not be billed for any portion of these services, even when the claim details include “Patient Responsibility”.

Important:
Federal and state regulations prohibit balance billing a Medi-Medi member for covered services. This is considered “improper billing”. Medi-Medi members cannot be charged for co-pays, co-insurance, or deductibles. In accordance with your contract, you agree to accept payment from HPSJ/MVHP as payment in full. For further guidance, please refer to the DHCS Balance Billing Fact Sheet at https://www.dhcs.ca.gov/wp-content/uploads/2025/10/Balance-Billing-Fact-Sheet-3-9-23.pdf and your contract agreement with HPSJ/MVHP.

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