To contact Utilization Management (UM) staff regarding UM questions or a free copy of criteria used to make medical necessity decisions during the utilization review process, please call the following number: 1-888-936-PLAN (7526). Staff are available to answer UM questions from 8:00 AM – 5:00 PM, Monday through Friday. Customer Services Representatives are available to answer general inquiries about UM issues such as the status of your request for approval of a service. For more specific UM questions regarding detailed clinical information or discussion about specific UM, Customer Service Representatives will transfer you to speak directly with Medical Management staff.
HPSJ staff are also available outside of normal business hours. HPSJ staff can receive calls regarding UM issues before 8:00 AM and after 5:00 PM. Callers who need assistance after normal business hours may leave a message via a secure Customer Services voicemail line. All voicemail messages are retrieved each day at 8:00 am. Responses to voicemails are returned no later than the next business day.
For members with hearing or speech impairments, HPSJ provides Telecommunications Device for the Deaf (TDD) and/or Telephone Typewriter (TTY) services. Please contact: (209) 942-6306. HPSJ also offers language assistance to discuss UM issues free of charge.
The Health Plan of San Joaquin’s mission is to continuously improve the health of our community. HPSJ supports its mission through our vision statement, which is to provide health care value and advance wellness.
Our affirmation statement about Utilization Management Incentives is clearly understood by all HPSJ staff involved in UM-decision making as follows:
- UM decision making is based only on appropriateness of care and services and existence of coverage.
- HPSJ does not specifically reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
If you have any questions, please contact our Provider Services Department at 209-942-6340.
Posted on June 17th, 2015 and last modified on May 29th, 2018.