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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).

Note: Failure to submit the provider dispute through DRE or on the HPSJ PDR form will be returned for completion and may result in a delay of processing and potentially could fall outside of the dispute processing guidelines set by DMHC.

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
processing.

If you have questions, please contact our Customer Service Department at 209-942-6320.

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