|Date:||September 4, 2019|
|To:||Health Plan of San Joaquin (HPSJ) All Providers & Facilities|
|From:||HPSJ Claims Department|
|Subject:||**Reminder** Provider Dispute Resolution (PDR) Submission
|Business:||Medi-Cal Managed Care|
Health Plan of San Joaquin (HPSJ) would like to remind providers and facilities of proper protocol for submitting Provider Dispute Resolutions (PDRs).
- Contracted Providers must submit a provider dispute online through the Provider Portal/ Doctors Referral Express (DRE) https://provider.hpsj.com/dre/default.aspx.
- Non-Contracted Providers must mail in provider disputes to the attention of the
Claims Department at: Health Plan of San Joaquin P.O. Box 30490, Stockton, CA
95213-30490 with the appropriate HPSJ Provider Dispute Resolution (PDR)
form. See attached form (one page). Also located at: https://www.hpsj.com/wp-content/uploads/2018/04/PDR-Notification-and-form_022718.pdf.
Provider Dispute Resolution (PDR) should only be submitted for the following reasons:
- Contract Dispute: Original claim did not pay per contracted or MCL rate
- Appeal of Medical Necessity/Utilization Management Decision: Original claim denied because of a denied authorization or partial authorization
- 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 you do not agree with the determination
If a claim was denied as a duplicate and you feel it denied in error, please make sure it was submitted with the appropriate documentation, modifiers, or corrected claim submission indicator before you submit a dispute.
If you are trying to submit corrections on a claim, please follow the Corrected Claim submission guidelines.
If a claim or claim line was denied for supporting documentation, please submit as
Correspondence with the requested information.
- Contracted Providers must submit Correspondence online through the Provider
Portal/Doctors Referral Express (DRE).
- Non-Contracted Providers must mail in Correspondence to the attention of the Claims Department at: Health Plan of San Joaquin, P.O. Box 30490, Stockton, CA 95213-30490, with the claim Remittance Advice identifying claim number and reason for additional documentation submission.
Note: Failure to submit the correspondence through DRE or clearly identify reason for
correspondence, the correspondence will be returned and may result in a delay of
If you have questions, please contact our Customer Service Department at 209-942-6320.