SOPs
Systems
HPSJ-MVHP.org
EOC
Provider Focus
100

If a Member indicates any difference in demographics from what HPSJ-MVHP has listed, CSR must complete a demographic update change.

Member Updates SOP

100

Claims processing and payment system. 

QNXT

100

Preventive health care guideline PDF document's to view it.

Immunizations 

100

You qualify for Health Plan because you qualify for Medi-Cal and live in one of these counties: Alpine, El Dorado, San Joaquin or Stanislaus. You might also qualify for MediCal through Social Security because you are getting SSI or SSP.

Who can become a member, page 16

100

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

200

The outbound ACD call script.

"Hello/Hi/Good morning/afternoon, this is (insert CSR name)from Health Plan of San Joaquin and Mountain Valley Health Plan returning your call. Please note all calls are recorded for quality and training purposes, How may I help you today?"

Customer Service Scripts/SOP

200

Claim images repository

Smart Data Solutions (SDS)

200
  • Report Fraud Waste and Abuse or a Privacy Incident
  • Create a myHPSJ Member Account
  • How to File Grievance or Appeals
  • Member Forms

Quick Links 

200

You must choose a PCP within 30 days of enrolling in HPSJ-MVHP.

Primary care provider (PCP), page 29

200

If a provider identifies an overpayment, the provider is required to inform HPSJ-MVHP 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

300

Member or Non-Contracted provider requests a copy of a Notice of Action (NOA), Authorization approval fax or denial fax and the authorization was submitted After 2/20/2024

Material Request SOP

300

Automated eligibility verification system

AEVS

300

Provides member benefits, rights, and responsibilities for HPSJ-MVHP Members.

EOC (Evidence of Coverage)

300

Services to obtain housing, a place to recover after a hospital or facility stay when one is not available, meals/medically tailored meals, a place to sober from alcohol or other drugs, help to improve your setting when you have asthma, shower grab bars and ramps, and help for you or your caregiver.

What is Community Supports, pg 78

300

HPSJ-MVHP 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

400

To provide guidance on filing appeals when a member does not agree with a modification, denial or deferment of an authorization or decision made by HPSJ or MVHP for which a notice of action was issued.


Member Appeals SOP

400

ID Card Repository 

Clarity

400

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

400

Your in-network provider must offer you an appointment within the time frames listed below.

Timely access to care, page 38-40

400

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

500

If the Member, their authorized representatives on file with HPSJ-MVHP, 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

500
Provider dispute resolutions repository
DRE
500

Useful guide for participating providers/practitioners with HPSJ-MVHP.

Provider Manual

500

▪ A complaint (or grievance) is when you have a problem with HPSJ-MVHP 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-MVHP's decision to change your services or to not cover them

Reporting and solving problems, page 97

500

What tool does a Non-Par Provider have access to for payment detail and how do they enroll?

 

Remittance Advice (RA) Tool / Calling Customer Service