Member Calls
HPSJ can determine members eligibility?
Members should be directed to their EW as HPSJ does not determine eligibility.
Provider calls requesting claim status, how many claims can a CSR verify over the phone?
5
For all of the following call scenarios that come in from the State, CSR must document under the current CS USE NON MEMBER ACCOUNT, HIPAA is not required and/or needed for these calls.
Survey Calls
You must choose a PCP within 30 days of enrolling in Health Plan
Primary Care Provider (PCP) Page 30
Automated Eligibility Verification Ssytem
Which HIPAA verification question should be asked on every member call?
Mailing Address
Provider calls states they received a refund request letter from HPSJ and would like for HPSJ to offset the cost. Where should the CSR document the call?
CSRs are to document all refund inquiry calls on the provider specific NPI,PMP or Provider name account
Member Demographic Updates must NOT be completed for inactive/termed members, non-members and newborn accounts.
Member Updates
Your in-network provider must offer you an appointment within the time frames listed below
Timely Access to Care Page 38
Paper claim form repository
SDS Smart Data Solutions
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
Provider offices can request to assign a PCP to a member without member consent?
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
If you need a specialist for your care, your PCP or another specialist will give you a referral to one.
Referrals Page 43
Access this system to view all provider appeals
DRE
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?
If the provider does not agree with the resolution of the dispute they have the right to appeal directly to Help Center, Department of Managed Health Care, 980 9th Street, Suite 500, Sacramento, CA 95814 within 60 business days from the date of this determination. Do not submit appeal to Health Plan of San Joaquin.
Claim Appeal: Provider Dispute
If you are under age 18, you can receive some services without a parent or guardian’s permission. These services are called minor consent services.
Sensitive Care (Minor Consent Services) Page 46
By entering Check Number 123456, You are able to view if it was sent EFT or mail.
Change Healthcare
Member calls and states they received a bill from a provider for $500. What steps must the CSR take on the call?
Check members eligibility, Claims on file for DOS being billed, and complete a balance billing assessment accordingly
Provider calls requesting assistance with billing, and asked to speak with provider services. Can provider services assist with billing inquiries?
Provider Services cannot assist with billing inquiries. CSR is to advise the provider to consult with their billing office, as HPSJ follows Medi-Cal Guidelines of billing.
If the caller is not the Requesting provider or Servicing provider CSR must not disclose any information to the caller from the authorization.
Authorization Status
There are some services that neither HPSJ nor Medi-Cal will cover, including, but not limited to:
▪ IVF▪ Fertility preservation ▪ Experimental services ▪ Home modifications ▪ Vehicle modifications ▪ Cosmetic surgery
Services You Cannot Get Through HPSJ or Medi-Cal Page 90
Information to quote Occupational Therapy
Benefit Dossier