Provider Portal
What system do providers utilize?
DRE
209-942-6302, 209-762-470
Timely filing for initial claim
365 days from date of service
TAT for processing of appeals
30-45 business days
Balance Billing Occurs
When providers bill a patient for the difference between the amount they charge and the amount that the patient's insurance approves
TAT for provider service access after supervisor approves request
3 business days
TAT for Routine Auth's and Urgent Auth's
Routine = 5 business days
Urgent = 72 hours
What is the mailing address for initial claims and corrected claims?
Health Plan of San Joaquin (HPSJ)
Paper Processing Facility
P.O. Box 211395
Eagan, MN 55121-2195
How many levels of appeals are providers able to submit?
3
TAT for Balance Billing
21 Calendar Days
Who is able to get access to RA Tool?
Non contracted and contracted providers
When members are admitted to hospital, how is inpatient auth initiated?
Facesheet
What is the frequency code for corrected claims?
7
365 days from date of process on claim they are trying to appeal
After gathering DOS/ BA from member, what is one key component we must verify before starting balance billing?
Verifying eligibility
What call type/call code is required when provider is requesting to speak with provider services
Provider Services - Provider Education
Needed/Requested
Who are we able to reach out if available nurse (Inpatient) or intake processor (Outpatient) is not available?
Inpatient CCRN for corresponding facility
Outpatient Intake
What is correct process of submitting a w-9 after claim denies for W-9?
Faxing denial RA along with w-9 to ps 209-461-2565
Attention to:
Claims Department Health Plan of San Joaquin
P.O. Box 30490, Stockton, CA 95213-30490
The only areas that we may refund a member for services paid
Mexico or Canada
List off 3 providers that must submit a confidentiality statement form due to being on LOA
UC Davis, UCSF, Lucille Packard, Stanford
1.Authorization number
2.Status of the Authorization
3.Admission/Service Date
4.Expiration Date
5.Servicing Provider
6.CPT Codes: If provider requests CPT codes information CSR must quote what is requested.
What must you quote when providing claim status?
•Claim Number
•Status: (Paid or Denied)
•Received Date: (Clean Date)
•Process Date: (Paid Date)
•Check Number (Only Paid Claims)
•Amount HPSJ-MVHP Paid (Only Paid Claims)
*IF quoting a denied claim in addition to the above you will also quote:
•Denial Reason: (Remit Message)
What information do we provide when we are quoting an appeal?
•PDR Number
•Status
•Received Date
•Resolution Type
•Resolve Date
•Letter Sent
•Level of Appeal
When you have the member on the line and member states bill is now in collections