Provider Alerts

It has been identified that the incorrect dispute type continues to be selected when submitting a Provider Dispute Resolution (PDR) through the DRE portal. A provider alert was issues April 14, 2021, indicating an Enhanced Provider Dispute Resolution Process requiring a complete and correct dispute form to be completed to ensure the PDR is appropriately routed for timely review. Please review the following dispute types and descriptions to help you select the PDR type you want to submit: Contract Dispute: Claim did not pay per contracted or MCL rate

• Appeal of Medical Necessity/Utilization Management Decision: Claim denied because of a denied authorization or partially denied authorization and requires additional clinical documentation attached for medical necessity determination. DO NOT USE if claim denied for invalid authorization, incorrect billing, additional documentation request, or disagree with payment or denial.
• Seeking Resolution of a Billing Determination: Do not agree with claim or claim line denial.
• Recovery Dispute: A letter was received regarding an identified overpayment and do not agree with the overpayment determination. A Recovery Request Letter must be received to use this dispute type.
• Seeking Resolution of a Supplemental Payment: Do not agree with the amount supplemental and/or denial of supplemental payment.

Page two of this provider alert provides additional guidance for the PDR submissions.

Provider Dispute Resolution Submission Reminder. 

If a claim or claim line was denied for “supporting documentation” please submit as Correspondence with the requested information. DO NOT submit a PDR.

If you are submitting corrections on a claim, DO NOT submit a PDR or Correspondence. Please follow the Corrected Claim submission guidelines. If the incorrect dispute type is selected or the incomplete form is submitted, the Provider Dispute Resolution (PDR) will result in an UPHELD determination with a request to resubmit.

**Billing Tip** If no authorization is required, leave the prior authorization or treatment authorization field blank. Entering any information other than a valid authorization will result in claim denial

Should you have any further questions, please contact our Customer Services Department at (209) 942‐6320. You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/.