Submit Claims

Paper claims must be submitted on a CMS-1500 or UB-04 claims form and mailed to HPSM at:

To be eligible for payment, all paper claims must be filed on fully and accurately completed ADA or Medi-Cal dental claim forms with the current CDT procedure codes. Please note; if using the ADA dental claim form, please use the most recent 2019 version. Claims may be suspended or denied when data items on claim forms are incomplete or incorrect.

Please mail dental claims to:

Using standard EDI 837 format

• Set up your user ID and password by calling Provider Services at 650-616-2106
• FTP (File Transfer Protocol) to www.hpsm.org using dial-in number 650-616-8062
• Plaintext only, migrating to 128-bit SSL encryption

Clearinghouse/Payer ID

• Change Healthcare (formerly Emdeon and Capario)
  • For 837 Professional: SX174   
  • For 837 Institutional: 12X74
• Office Ally: HPSM1
• WayStar: HPSM1

Only CMS-1500 claims can be submitted through our Provider Portal at this time.

Claims Submission Instructions

•  Submitting Claims and Encounter Data
•  Required Data Items for CMS-1500
•  Required Data Items for UB-04
•  Explanation Codes for Claims Payment

Dental providers can submit electronic dental claims through their existing system/clearinghouse with the following information:

Payer Name: Health Plan of San Mateo Dental

Payer ID: HPSMD

To get set up with a clearinghouse please contact the Provider Services department at 650-616-2106 or psinquiries@hpsm.org