SOPs
If a Member indicates any difference in demographics from what HPSJ has listed, CSR must complete a demographic update change.
Member Updates SOP
Claims processing and payment system.
QNXT
HPSJ makes finding a doctor easy!
Find a Provider
You qualify for HPSJ because you qualify for Medi-Cal and live in San Joaquin or Stanislaus County. You may also qualify for Medi-Cal through Social Security because you are receiving SSI/SSP.
Who can become a member, page 11
Paper claim submission are mailed to address below: Health Plan of San Joaquin (HPSJ) Paper Processing Facility P.O. Box 211395 Eagan, MN 55121
To submit claims electronically, providers must establish an account with a clearing house of choice.
SECTION 10: CLAIMS SUBMISSION
Section 10 – Page 2
HPSJ will notify the Provider in writing through a separate overpayment notice clearly identifying the claim number(s), member(s), date of service, explanation of overpayment and interest and penalties that may be due.
Recovery/Refund Requests SOP
Claim images repository
Smart Data Solutions (SDS)
Quick Links
You must choose a PCP within 30 days of enrolling in HPSJ.
Primary care provider (PCP), page 23
If a provider identifies an overpayment, the provider is required to inform HPSJ and return the overpayment to HPSJ within thirty (30) working days from the date the provider identifies the overpayment.
CLAIM OVERPAYMENT
Section 10 – Page 5
To ensure request for Eligibility letters, EOC, Member Rights and Responsibilities, Parental Permission for Transport of Minor, and copies of HPSJ ID cards processed within in 24 business hours of request in preferred language.
Material Request SOP
Automated eligibility verification system
AEVS
Provides member benefits, rights, and responsibilities for HPSJ Members.
EOC (Evidence of Coverage)
Some HPSJ members can receive care through Kaiser Permanente physicians and Kaiser Hospitals, if they meet the limited and specific qualifications for enrollment. If Kaiser membership reaches a threshold amount, no members can join Kaiser regardless of whether they meet the criteria.
Delegated Model, page 28
HPSJ maintains a dispute resolution process to support the review and resolution of provider concerns including, but not limited to, disputes regarding claim payments and/or denials, utilization management decisions (authorizations) and recoupment requests.
PROVIDER DISPUTE RESOLUTION (PDR)
Section 12 – Page 6
To provide clear guidance on how to review and quote an authorization status to members and providers.
Authorization Status
Clarity
As an HPSJ member you have access to a variety of tools and resources to help you find the information you need fast an easy. On this page you will find files such as the Privacy Practices, Evidence of Coverage, Provider Directory and much more!
Member Tools
Your in-network provider must offer you an appointment within the time frames listed below.
Timely access to care, page 30
Urgent Request: Within seventy-two (72) hours of receipt of Authorization request
▪ Routine Request: Within five (5) Working Days of receipt of Authorization request.
TURNAROUND TIME FOR PRIOR AUTHORIZATION
Section 8 – Page 8
If the Member, their authorized representatives on file with HPSJ, or their provider, requests to continue care with an out-of-network primary care provider (PCP) or specialist that the member has seen at least once during the 12 months prior to the date of his or her initial enrollment.
Continuity of Care Request
Useful guide for participating providers/practitioners with HPSJ.
Provider Manual
▪ A complaint (or grievance) is when you have a problem with HPSJ or a provider, or with the health care or treatment you got from a provider
▪ An appeal is when you don’t agree with HPSJ’s decision to change your services or to not cover them
Reporting and solving problems, page 83
Electronic Funds Transfer (EFT) is a great way to receive your payments from HPSJ faster. Visit www.changehealthcare.com/support/customer-resources/enrollment-services to enroll in EFT, or download and send completed forms via email to EFTenrollment@ChangeHealthcare.com or fax to (615) 238-9615.
ELECTRONIC FUNDS TRANSFER (EFT)
Section 11 – Page 2