Provider Manual | Section 5

Provider Disputes

Provider Disputes

If you have a dispute regarding a claim you submitted to HPSM, you may participate in HPSM’s Provider Dispute Resolution (PDR). This process applies to all lines of business for contracted as well as noncontracted providers with one exception. This exception is for non-contracted providers who have a dispute regarding a claim for services provided a CareAdvantage member. In this case, the dispute must be resolved following federal guidelines that apply to Medicare managed care plans which are described at the end of this section.

If a provider is dissatisfied with aspects of HPSM’s operations, or with another providers, or member’s activities or behaviors, the provider may contact HPSM’s Provider Services Department at 650-616-2106.

If a provider wants to submit an appeal of a denial of a service authorization on behalf of a member, please refer to the Member Complaints Section of this Manual. HPSM’s PDR process must not be used to resolve member appeals of pre-service authorization denials. Such appeals should be submitted through the member appeals process described in “Section 3: Member Complaints.

Provider Dispute Resolution

HPSM offers the Provider Dispute Resolution (PDR) for Providers to resolve claims issues. This process includes a written notice to HPSM requesting reconsideration of a claim or a bundled group of substantially similar claims. You can address any of the following concerns through HPSM’s Provider Dispute Resolution Process:

  • Claims believed to be inappropriately denied, adjusted, or contested.
  • Resolution of a billing determination or other contract dispute.
  • Disagreement with a request for reimbursement of an overpayment of a claim.
  • If a claim has been underpaid.
  • A procedure was denied as inclusive to another procedure in error.
  • Utilization management decisions once a service has been provided.

Note: The PDR process should not be used to request retro authorization. Instead, retro authorization requests should be submitted directly to HPSM’s Health Services department.

If the dispute is not about a claim, a provider should provide a clear explanation of the issue. If a provider dispute is submitted on behalf of a member or group of members, the dispute will be resolved through the member grievance process and not through the provider dispute resolution process. HPSM will, however, verify the member’s authorization to proceed with the grievance.

Providers should submit their dispute through submission of a Provider Dispute Resolution Request form, including the following information:

  • Provider name.
  • NPI billed on claim.
  • Provider contact information.
    • Identification of the disputed item, including;
    • The original HPSM claim number.
    • Date of service.
    • A clear description of the basis upon which the Provider believes the payment amount, request for additional information, request for the overpayment of a claim, denial, adjustment, or other actions is incorrect.

A sample of the Provider Dispute Resolution form is included in this section. The form is also available on HPSM&trongrsquo;s website at www.hpsm.org. You may fax your PDR request to 650-829-2051 or if you want to print the form and send it via mail, please send your PDR to the address below:

Health Plan of San Mateo
Attn: Provider Disputes
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Time Period for Submissions

Provider disputes should be sent within 365 days of the date when a claim was denied. . HPSM will return any provider dispute that is lacking the information required (as previously noted) if it is not readily accessible to HPSM. In this case, HPSM will clearly identify in writing the missing information necessary to resolve the dispute. A provider may submit an amended provider dispute within 30 working days of the date of receipt of a returned provider dispute requesting additional information. If the additional information is not submitted, the dispute will be closed.

Time Frames for Resolutions

HPSM will send an acknowledgement letter to the Provider within 15 working days of receipt of the dispute mail.

HPSM will resolve a provider dispute or amended provider dispute and issue a written determination stating the pertinent facts and explaining the reasons for its determination within 45 working days for Medi-Cal and 60 calendar days for CareAdvantage disputes from Contracted providers after the date of receipt of the provider dispute or the amended provider dispute. If an investigation shows that a claim was originally denied or paid incorrectly due to HPSM error, any interest and penalty due for late payment will be included in the claim payment. Payment will be made within 5 working days from the issuance of HPSM’s determination. If the dispute involves an issue of medical necessity or utilization management for a service that has not been provided, the Provider should appeal this through HPSM’s Appeal Process. To understand how to appeal, please refer to the “Section 3: Member Complaints section of this manual.

Non-Contracted Provider Disputes —CareAdvantage Only

Non-contracted providers who want to submit a CareAdvantage Appeal of a benefit determination on behalf of a member, must submit the appeal and waiver of liability (see attachment below) to the Grievance and Appeals Department according to “Section 3: Member Complaints.” However, unlike other lines of business, providers must sign a waiver of liability statement attesting that they waive any right to collect payment from the member for HPSM to process the appeal.

Non-contracted providers, who want to submit a dispute regarding a payment decision, must submit the dispute through the Provider Dispute Resolution process.

Corrected and Rebilled Claims

Corrected Claims

Corrections by providers to previously submitted claims are not considered provider disputes. Corrections can be submitted using one of the following options.

Rebilled Claims

Most denied claims and service lines can be rebilled as a new claim or updated/corrected when the claim is submitted in a timely manner.

Rebill when HPSM denies a claim because of incorrect information supplied on the claim form. In such cases you can rebill these claims by submitting a new claim form that has corrected the issue that triggered the denial. For example, you can rebill for claims that HPSM denied because of:

  • Lack of required information (e.g., NDC, primary insurance information, rendering NPI, modifiers, medical records/invoice, and HIPPS codes).
  • Invalid data (e.g., ICD-10 codes or sets, invalid modifier for the service/item).

How to Rebill Claims

You can rebill HPSM using the same method used to submit claims. Please submit denials requesting additional documentation on paper and address to:

Health Plan of San Mateo
Attn: Claims Processing
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Dental Claims

For dental claims, please submit denials requesting additional documentation on paper and address to:

HPSM Dental
PO Box 1798
San Leandro, California 94577

Rebill Submission Timeframes

Medi-Cal Rebill within 6 months of service date CareAdvantageWithin 12 months of service date HealthWorx Within 12 months of service date

Updates or Claim Corrections

Update or correct claims using the Claims Correction Request Form when you want to modify a previously submitted claim line that has already been processed. For example, you can correct or update claim(s) or claim line(s) when you want to:

  • Make changes to paid service line(s).
  • Report overpayments (including retro application of share of cost deductions).
  • Request reimbursement for a claim or service line that was originally denied as a duplicate.

How to Correct or Update Claims

  1. Complete the Claims Correction Request Form completely: be sure to include all the required information.
  2. Attach a copy of the corrected claim form.
  3. Submit the form to HPSM by fax or mail:
    1. Fax: 650-829-2051
    2. Mail :Health Plan of San Mateo, Attn: Claim Corrections 801 Gateway Boulevard, Suite 100 South San Francisco, California 94080

Additional Information

Be sure to only submit corrections or updates after receiving the final disposition of the claim in question.

Providers are encouraged to use the rebill process noted above when possible as this will expedite reimbursement.

To check the status of a claim call 650-616-2056 or email claimsinquiries@hpsm.org. To submit a formal appeal or dispute use the standard appeal or dispute process, not the Claim Correction Request form.

Provider Grievances

If a provider is dissatisfied with aspects of HPSM’s operations or with a member’s behavior, the provider may contact HPSM’s Provider Services Department at 650-616-2106.

End of Section 5: Provider Disputes