Eligibility/ HIPAA
HPSJ can determine members eligibility?
Members should be directed to their EW as HPSJ does not determine eligibility.
What is the TAT for ps to call a provider back?
5 business days
Member calling to request COB to be removed with HPSJ
Coordination of Benefits: Health Plan Secondary Insurance
What is the TAT for HCO to process an application?
45 Business days
Which HIPAA verification question should be asked on every member call?
Mailing Address
Can non par providers request access to the DRE?
No
Member Demographic Updates must NOT be completed for inactive/termed members, non-members and newborn accounts.
Member Updates
Behavioral benefits for Alpine County
Alpine County Behavioral Health Services
Where can CSR find the rate code of a member in essette?
What form does a spouse need to fill out to speak on behalf of the member is they are not authorized on the account?
Authorization for use and disclosure
What form is needed to request DRE access?
DRE confidentiality form
When transferring a provider using the Provider Service queue, voice-mails left will be distributed among Provider Service Representatives and calls returned within 5 business days.
Provider Service Transfers
Can members see non par providers for sensitive services and is PA needed?
Yes, members can see non par providers for sensitive services. PA is not needed, but if services are preformed inpatient PA will be needed.
advice to contact their EW, HPSJ does not determine eligibility.
What form does a grandparent need to fill out in order to speak on behalf of a grandchild?
Caregiver affidavit
If a member has two last names the provider must verify both or else we cannot assist them?
Providers only need to validate one of the members last names.
Caller requesting Physical therapy benefits
Benefit Dossier; Benefit scripts
Caller requesting Transgender benefits, CSR must
transfer the call to CMHN and advice to leave full name, Health Plan ID # or CIN #, best contact number and if it’s okay to leave a VM, with the reason for call
If a CSR has an issue with language line, what must the CSR do?
send email to csleadership
When can a onetime exception be made to a caller?
Member rate code shows SPD, they are not able to speak for themselves, and they have not been assisted within the past year. Consent will also be needed by leadership.
Before transferring a provider to PS, what must the csr do and advice the provider?
CSR must complete an assessment and advice the provider to leave detailed message including name, best contact number, reason for the call and call reference number
If a caller is new to HPSJ and is requesting to stay to current specialist
Continuity if care request
Parent calling for a minor that is needing a transplant, what must CSR advice?
State law requires children who need transplants to be referred to the California Children’s Services (CCS) program to see if the child is eligible for CCS.
If the child is eligible for CCS, CCS will cover the costs for the transplant and related services.
If the child is not eligible for CCS, then Health Plan will refer the child to a qualified transplant center for evaluation. If the transplant center confirms the transplant would be needed and safe, Health Plan will cover the transplant and related services.
Member states they no longer have a primary insurance and CSR determines that there isn't a COB showing in essette nor QNXT, CSR must
Run Aves to verify if a primary insurance is listed, if so member must contact their EW