Claims Corner | Post date: October 8, 2018

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October 2018 – Claims corner newsletter


Opioid 7-Day Supply Limit for Initial Fill

Effective 12/1/2018, all initial fills of opioid prescriptions will be limited to a seven (7) day supply.
To reduce the potential for chronic opioid use or misuse, HPSJ is implementing this safety limit on initial opioid prescription fills for treatment of acute pain.
This is based on the CDC recommendation: “When opioids are used for acute pain, clinicians should prescribe the lowest dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids […] more than seven (7) days will rarely be needed.
Prescriptions for patients newly starting on opioids will not require authorization when using up to a seven (7) day supply. Larger quantities exceeding a seven (7) day supply will require prior authorization. For more — including information on subsequent fills, patients with documentation of a terminal illness or receiving palliative care — see the HPSJ Provider Alert of September 20, 2018 at

COBA – Coordination of Benefits Agreement — REMINDER

Per HPSJ Provider Alert of February 26, 2018
Any claims submitted to Medicare by your office on or after January 01, 2018 will be received by HPSJ via an electronic submission from CMS/Medicare.
COBA You no longer have to submit your Medicare/Medi-Cal member paper claims and Coordination of Medicare Benefit’s (COMB’s) to Health Plan of San Joaquin for processing.

Flu Season: Spreading the Word, NOT the Flu

It’s official: The 2018-2019 Flu Season has begun.
Flu shots are a covered benefit for HPSJ members and we want to make sure that your patients know to get the vaccines when appropriate. For the HPSJ pharmacy benefit, the coverage is as follows for flu vaccines:

    • All vaccines EXCEPT FluZone HD (High Dose)
      • Only for patients age 19 and older
    • For younger than 19 years old, vaccines are covered under the VFC (Vaccines for Children) Program
      •  HPSJ members can go to their doctor’s office or clinic

If you feel that you or your billing department can benefit from Medi-Cal billing refresher training, visit the Medi-Cal website at TrainingCalendar.aspx to sign up for seminars and/or e-learning courses.