SOPs
If a Member indicates any difference in demographics from what HPSJ-MVHP has listed, CSR must complete a demographic update change.
Member Updates SOP
Claims processing and payment system.
QNXT
Preventive health care guideline PDF document's to view it.
Immunizations
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
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
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
Claim images repository
Smart Data Solutions (SDS)
Quick Links
You must choose a PCP within 30 days of enrolling in HPSJ-MVHP.
Primary care provider (PCP), page 29
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
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
Automated eligibility verification system
AEVS
Provides member benefits, rights, and responsibilities for HPSJ-MVHP Members.
EOC (Evidence of Coverage)
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
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
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
ID Card Repository
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 38-40
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-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
Useful guide for participating providers/practitioners with HPSJ-MVHP.
Provider Manual
▪ 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
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