For a detailed description please click on any of the questions below.
You may have been getting care from another doctor or hospital before you were an HPSJ Member for:
- a serious chronic condition or acute condition
- a terminal illness
- a pregnancy
- care for a child (up to 36 months of age) or
- a planned surgery or procedure
If that doctor or hospital is not one of our providers, you may be able to continue to get the care you need if the doctor or hospital agrees with HPSJ to do so. For more information, or to request a copy of this policy, call HPSJ’s Customer Service Department at:
(209) 942-6320, or 1-888-936-PLAN (7526), toll-free (209) 942-6306 (Hearing Impaired – TTY/TTD)
Yes. Use the Provider Directory to choose a PCP for yourself. Also, choose a PCP for everyone in your family who has HPSJ. You can choose a different PCP for your family members. A PCP can be a family practitioner, general practitioner, internist, pediatrician, OB/GYN or clinic. If you choose a clinic, you may also have to choose a provider that works at that clinic. If you have recently had a baby, remember to choose a PCP for your newborn.. You can choose or change your PCP online through the member portal or by calling (209) 942-6320, or 1-888-936-PLAN (7526), toll-free (209) 942-6306 (TTY/TTD).
You may also choose a doctor within the local Federally Qualified Health Center (FQHC) for your primary care. If you are a Native American, you can get services at any Indian Health Service Facility. You can also disenroll from HPSJ at any time and get services through the Medi-Cal fee-for-service program. You also have the right to not enroll in a Medi-Cal Managed Care plan.
For information on the availability of the FQHC and Indian Health Service Facility clinics, and how to get services at these clinics, call HPSJ’s Customer Service Department at: (209) 942-6320, or 1-888-936-PLAN (7526), toll-free (209) 942-6306 (TTY/TTD)
If you do not choose a PCP within 30 days after you enroll, we will assign you a PCP. The PCP’s name will be on your ID card. If you do not want that PCP, call the Customer Service Department right away to choose another PCP or change your PCP online using HPSJ’s member portal.
It is important that you have a good relationship with your PCP. It is also necessary that you choose a PCP that is located in a place you can get to for appointments. If you want to change your PCP, choose another provider from our Provider Directory. If you need help finding a PCP that speaks your language or meets your needs, our Customer Service Department can assist you. You cannot see another PCP without telling us first.
Sometimes your PCP may ask that you be assigned to another PCP. This may be because you do not keep your appointments, do not follow the PCP’s medical advice, or disrupt the office. Your PCP can not ask that you are assigned to another PCP because of your medical condition.
The Provider Directory shows you which providers are taking new patients. Providers who are not accepting new patients are marked with a (*). If you were with a provider before you enrolled in our plan, that provider may let you continue as a patient. If a PCP’s office is closed to new patients, you will have to select another PCP.
If you need hospital care, your PCP will decide which hospital you go to. The hospitals are also listed in the Provider Directory.
Dental services are not covered services under the Medi-Cal managed care contract. Beneficiaries receive dental services through Denti-Cal or through a Dental Managed Care plan. Please visit the Denti-Cal website for more information. You can also call the Denti-Cal Beneficiary at:
Telephone Service Center: (800) 322-6384
Hearing Impaired (TTY): (800) 735-2922
The information changes often. You can call a provider to see if they are taking new patients or, you can call the Customer Service Department at:
(209) 942-6320, or 1-888-936-PLAN (7526), toll-free (209) 942-6306 ( Hearing Impaired -TTY/TTD)
You can see your Primary Care Physician or PCP for routine care and when you are sick. Call your PCP and make an appointment.
When you call to make an appointment, you may not be able to see the provider as soon as you want. HPSJ has standards for all participating providers for scheduling appointments. The wait times listed below apply to all HPSJ providers: PCPs, specialists, ancillary and mental health providers:
Urgent Care Services that do not require an authorization
Within 48 hours of a request for an appointment
Urgent Care Services that require an authorization
Within 96 hours of a request for an appointment
Within 10 business days of a request for an appointment
Non-Urgent Specialty Care
Within 15 business days of a request for an appointment
Non-Urgent Mental Health Care
Within 10 business days of a request for an appointment
Non-Urgent appointments for ancillary services
Within 15 business days of a request for an appointment
If you are not sure whether you have an emergency or if you need urgent care, call your PCP’s office, even during the hours that your PCP’s office is normally closed. Your PCP or the doctor on-call will be able to tell you how to handle the problem at home or if you should go to an urgent care center or a hospital emergency room. This is called triage or screening services.
You can also call the Advice Nurse Line 24 hours a day, 7 days a week for triage and screening services at 1-800-655-8294.
- Manages your health care services
- Provides most of your health care, including preventive services
- Refers you to a specialist when you need one
- Authorizes and arranges for needed hospital care
At your first visit, your PCP will also check to see if you need to see a dentist. If needed, you will be referred to Denti-Cal.
The following are the most common services you get from an OB/GYN:
- Breast examination
- Gynecological examinations and treatment
- Pap smear and
- Prenatal care
- Preventive care
- Urgent or Emergency care
- Family planning
- HIV testing and counseling
- First treatment for a sexually transmitted disease
If HPSJ and your PCP approve it, you will need only one referral. We will make a decision about the referral within 3 (three working days. The referral will be made to the Specialist within 4 working days after the decision is made.
If you think you need an extended referral, talk to your PCP. For more information on specialty providers or extended referrals, call the Customer Service Department at: (209) 942-6320, or 1-888-936-PLAN (7526), toll-free (209) 942-6306 (Hearing Impaired – TTY/TTD).
- Services out of the HPSJ service area (but not for emergency and urgent care services)
- Outpatient surgery, long-term therapy, or specialized treatments
- Durable Medical Equipment (DME), Medical Supplies, Orthotic and Prosthetic Devices
If we do not approve a requested service, we will tell you why. You will receive a letter explaining why the authorization was not approved, or denied. If you do not agree with the explanation given, you may appeal the decision by filing a complaint. For information on how to file a complaint, see “How do I file a complaint” section of your Evidence of Coverage.
To learn more about how we make those decisions, ask the Customer Service Department for a copy of our medical necessity guidelines.
If you see a provider that does not have a contract with us, without our approval, HPSJ is not responsible for the care you receive from that provider.
You can get a second opinion from a participating provider for certain services, including:
- treatment or diagnoses of serious or life-threatening conditions
- complex cases or cases with conflicting test results
- cases where the Member does not respond well after an appropriate amount of time
To get a second opinion, you can request to be referred to doctors specializing in that area of medicine. Most of the time, the second opinion must be from a HPSJ doctor. However, if there is not an HPSJ doctor qualified to see you, we will authorize a second opinion from a provider outside of our network.
If you do not know which doctor to see for a second opinion, ask your doctor or call HSPJ for a recommendation.
Once you decide who you want to see, ask your doctor or HPSJ to refer you. Then make an appointment to see one of these doctors. You must get the second opinion within 30 days after the first opinion, or as soon as possible. If the second opinion is different from the first opinion, you or HPSJ can ask for a third opinion.
HPSJ will let you know when your request for a second opinion is approved. For a routine condition, we will let you know within 5 working days of your request. If your case is urgent, we will let you know within 72 hours of your request.
If we deny your request, we will let you know within 24 hours of our decision. If you do not agree with our decision, you can file a complaint with the Department of Managed Health Care (Section 2. <em>Members Rights and Responsibilities.)</em>
There is no cost to you for a second or third opinion, if HPSJ approves it first. For more information on second opinions, call the Customer Service Department at:
(209) 942-6320, or 1-888-936-PLAN (7526), <em>toll-free </em>(209) 942-6306 (TTD/TTY)
Urgent Care is care you need right away to and to keep your medical condition from getting worse. Some examples of urgent care are:
- Sore throat
- Minor cuts
You do not need to ask us for approval first before getting emergency care or urgent care. You do not have to see a participating provider for emergency or urgent care.
If you need care during normal business hours, call your PCP. His or her staff will make an appointment for you, or tell you where to go for care.
If you are inside HPSJ’s Service Area and you need urgent care, you should call your doctor for advice. If you can’t reach your doctor, or if it is after normal business hours or on the weekends you can call the Advice Nurse at 1-800-655-8294. The nurse will help you decide what to do.
If you are outside HPSJ’s Service Area and need urgent care, you must call HPSJ within twenty-four (24) hours of getting urgent services, or as soon as you are able to. A provider outside of HPSJ’s Service Area may send you a bill for urgent services. If you do get a bill, refer to “If You Get A Bill” in your Evidence of Coverage.
Emergency services are covered inside and outside of HPSJ’s service area. Emergency services do not need approval from HPSJ, and are provided at no cost to you.
An emergency is a medical or psychiatric condition that could get worse if you don’t get immediate care by:
- Placing your health in serious danger,
- Causing serious harm to bodily functions, or
- Causing serious harm to any bodily organ or part.
- Active labor
- Broken bones
- Chest pain
- Severe burns
- Drug overdose
- Severe cuts that won’t stop bleeding
- Psychiatric emergency conditions
If you think you have a health emergency, call 911. You are not required to call your doctor before you go to the emergency room. Do not use the emergency room for routine (regular) health care.
If you have an emergency when you are not in HPSJ’s Service Area, you can get emergency services at the nearest emergency facility. Emergency services do not require a referral or okay from your PCP doctor.
If you are admitted to a hospital not in HPSJ’s network or to a hospital your PCP doctor or other provider does not work at, HPSJ has the right to move you to a network hospital as soon as it is medically safe to do so. You may need hospital care after an emergency to stabilize your condition. This is called post-stabilization care. If you do, the hospital will call HPSJ to ask for an okay.
The hospital will ask you for your ID card. If you don’t have your ID card, tell the hospital to call HPSJ. If you do not agree to being transferred to a contracted hospital that can provide the care you need, you may have to pay for the post-stabilization services.
Your PCP doctor must provide follow-up care when you leave the hospital.
For maternity related Emergency Services, refer to the Pregnancy and Maternity Services” of your Evidence of Coverage under “What Does HPSJ Cover?”
If your doctor is no longer part of our plan, you may be able to continue to see that doctor if the doctor agrees with HPSJ to do so and if you are being treated for:
- A serious, chronic condition or acute condition
- A pregnancy
- A terminal illness
You may also continue with that doctor if:
- You were receiving care for your baby (up to 36 months of age)
HPSJ approved a surgery or procedure with that doctor
Remember: the doctor does not have to continue caring for you. For more information, or to request a copy of this policy, call HPSJ’s Customer Service Department at: (209) 942-6320, or 1-888-936-PLAN (7526), toll-free (209) 942-6306 (TTY/TTD)
For routine (regular) care, all health care services are provided in HPSJ’s Service Area. Routine care outside of HPSJ’s Service Area is not covered.
In most cases, you need to get care within HPSJ’s network and within HPSJ’s Service Area. However, when you are not in the Service Area (San Joaquin or Stanislaus counties) you can always get emergency care at the nearest emergency facility.
If you get care from a non-contracted provider (a doctor or other provider that is not a part of HPSJ’s network) or outside of HPSJ’s Service Area, you may be billed by the provider and you may have to pay, except for emergency care, urgent care, family planning and for sexually transmitted disease (STD) testing services. You can learn more about this under “What to do in an emergency?” section of your Evidence of Coverage.
HPSJ pays for all covered medical services provided by your PCP doctor, contracted specialist or for an emergency. You should not get a bill for any services covered by HPSJ. Please call Customer Service toll-free at 1-888-936-PLAN (7526) right away if you receive a medical bill. You may get a medical bill if you go to a doctor that does not work with HPSJ or is located outside of HPSJ’s Service Area. If this happens, you may be billed by the doctor and you may have to pay for services that are not covered by HPSJ. If you pay the bill, keep a copy or record of your payment. Send a copy of your payment to HPSJ for review. If the bill is for covered or authorized services, you may receive a refund from HPSJ.
You should not be billed for emergency care, urgent care, the care required to stabilize an emergency condition, family planning services, or for sexually transmitted disease testing at a clinic. If you receive a bill, do not pay it. Call HPSJ right away to assist you with the issue.
Do not pay medical bills you get from a collection company. If you get a bill for covered services and need help or if you want to file a complaint, call the Customer Service Department at (209) 942-6320, or 1-888-936-PLAN (7526), toll-free (209) 942-6306 (TTY/TTD).
HPSJ partners with hundreds of local and retail pharmacies. You can find a list of pharmacies in HPSJ’s Provider Directory, or call Customer Service toll-free at 1-888-936-PLAN. Medi-Cal Members should not be asked to pay for prescription drugs. Call HPSJ if you are asked to pay for a prescription.
HPSJ partners with hundreds of local and retail pharmacies. You can find a list of pharmacies in HPSJ’s Provider Directory, or call Customer Service toll-free at 1-888-936-PLAN.
- Choose a participating pharmacy near you.
- Bring your prescription to the pharmacy.
- Give the prescription to the pharmacy with your HPSJ member ID card. This will help the pharmacy fill your prescription.
- Make sure you give the pharmacy your correct address and phone number.
- Make sure the pharmacy knows about all medications you are taking and any allergies you have to any medicine.
- If you have any questions about your prescription(s), ask to speak with the pharmacist to get more information.
Posted on June 16th, 2015 and last modified on August 6th, 2015.