Frequently Asked Questions
Frequently asked questions for Health Plan of San Joaquin providers. For a detailed description please click on any of the questions below.
What is Health Plan of San Joaquin’s reimbursement model?
We offer both capitation and fee-for-service contracts. Our capitation contracts include additional incentives and reimbursements not typically offered in traditional capitation arrangements. We will work with you to identify a mutually rewarding reimbursement method.
Does Health Plan of San Joaquin offer physician incentives such as pay-for-performance?
We offer incentives for physicians who are effective in helping patients meet certain preventive health and care measures. In addition, we offer incentives for:
- Board Certification
- Offices with expanded appointment access
- CCS-paneled physicians Physicians who have a complex patient panel as compared to peers
How does the credentialing process work? How long does it take to get credentialed and how soon can I start seeing Health Plan of San Joaquin members?
We use the standard California Credentialing Application. The credentialing process typically takes 60 days. You will be able to see Health Plan of San Joaquin members as soon as you are approved through the credentialing process.
What hospitals are you contracted with?
We have contracts with most of the hospitals throughout our service areas in both San Joaquin and Stanislaus counties. For a listing of our contracted hospitals, please use our “Find A Provider” tool.
What specialists are in Health Plan of San Joaquin’s network?
We have a growing and diverse provider network. A list of specialists by line of business can be found by using our “Find A Provider” tool or through our secure portal.
What is your pharmacy network?
We have a comprehensive network including locally owned pharmacies as well as national chains such as Costco, CVS, K-Mart, Rite-Aid, Safeway, Save-Mart, Walgreens, and Wal-Mart.
What medications are covered?
We have a preferred drug list that encompasses most therapeutic categories. Some medications require prior authorization. You are able to conduct a search online via our “Searchable Formulary”. Health Plan of San Joaquin’s Pharmacy and Therapeutics (P&T) Committee, which consists of area providers and pharmacists, meet quarterly and providers are notified of changes promptly after each P&T meeting.
What types of after-hour services are available to serve members?
We provide a 24-Hour Advice Nurse to all of our members. Members can call and speak to a registered nurse or access the audio health library for recorded messages on over 500 related health topics. In addition, we offer incentives to providers with extended hours and we are contracted with several Urgent Care facilities throughout the service area. Members and providers can call out Customer Service Department weekdays until 7:00 pm.
Does Health Plan of San Joaquin offer Case Management services?
Our Case Management program includes facilitated nurse practitioner home visits when needed. Case Management can be initiated by the provider or by Health Plan of San Joaquin. Our Care Management team also includes Social Workers who may assist with social service needs as well. We also offer a Disease Management program that provides interventions by severity of disease (stratified by claims history). The program includes member education, provider reports, provider contact, pharmacist intervention and when necessary, referral into our Case Management program. Disease Management programs include Asthma and Diabetes.
How do I submit Prior Authorizations? What is the turnaround time for a Prior Authorization?
Prior Authorizations can be requested either online via our secure provider portal, Doctors Referral Express (DRE) or by fax. The turnaround time for a Prior Authorization is dependent on the status you request. The three Prior Authorization statuses include:
- Routine – 5 business day turnaround
- Urgent – 72 hour turnaround
How does Health Plan of San Joaquin handle claim submissions?
You can submit claims electronically or by paper. For electronic claim submissions, we partner with two clearinghouses: Office Ally and Emdeon. We encourage electronic submissions since submitting paper claims increases reimbursement turnaround time.
Does Health Plan of San Joaquin offer Electronic Funds Transfer (EFT) or provide Remittance Advices (RAs) electronically?
We have selected Emdeon as out electronic payment and remittance reporting provider. This is no cost to you to use Emdeon ePayment and enrollment is free! Medical Providers:
- To enroll by fax or by mail, you can download the enrollment form at emdeon.com/epayment/enrollment.
- Enroll online at emdeon.com/eft
- Enroll by mail, send complete form to:
What kind of orientation and ongoing support will you provide?
You will receive a new provider in-service within 10 days of your contract execution date. At that time, you and your staff will receive an overview on a number of key areas, including direction on billing options, and how and when to submit referrals and authorizations. Also, we have a Provider Policy and Procedure Manual located on our secure website for your convenience.
Where are your office locations?
You can learn more about our office locations by visiting the “Contact Us” page.
How can I communicate with Health Plan of San Joaquin’s administration?
You can contact our Medical Director directly. You may also join Health Plan of San Joaquin’s Physician Committee to share ideas and communicate ways in which we can best serve you and your patients.