Provider Manual | Section 1
The Health Plan of San Mateo (HPSM) provides health services to more than 130,000 residents of San Mateo County. All HPSM programs are designed to emphasize easy access to quality care for our members.
This manual contains policies and procedures relevant to providers that are contracted with HPSM. Please be aware that different policies and procedures may apply depending on the program(s) with which you are contracted.
The purpose of this manual is to familiarize participating providers and their staff with HPSM operations. It is designed as a reference tool to assist you with the administrative tasks related to accessing and providing comprehensive, effective, and quality healthcare services to HPSM members. HPSM reserves the right to revise these policies and procedures at our sole discretion and at any time.
If you have any questions regarding the information contained within, please contact the Provider Services Department at PSInquiries@hpsm.org.
Healthy is for everyone!
HPSM’s mission is to provide members with access to quality healthcare services delivered in a cost effective and compassionate manner. That means our primary concern is keeping our members healthy and ensuring they have access to high quality healthcare when they need it.
Providers may access a variety of plan information when visiting the HPSM website: www.hpsm.org. The site offers information on HPSM programs, up-to-date participating provider information (including a provider directory, Member Handbook/Evidence of Coverage for each line of business, eligibility verification, clinical guidelines, preventive health guidelines, disease management programs, authorization forms, and the latest HPSM news), health tips, plan history, and organizational philosophy.
HPSM maximizes the use of technology to assist our providers to better serve our members. HPSM’s website also offers resources for development with the Provider Learning Lab. The Learning Lab is updated frequently with tutorial videos and other useful content to help HPSM providers serve our community.
Provider Manual Updates
This manual will be updated annually as policies, programs, and procedures change. Updates and supplements will be distributed as they occur and will be available as downloadable documents from our website for your convenience.
Please be sure to replace the existing pages in the manual upon receipt of any updates. This will assure that the manual you have available is the most current.
The following section briefly describes HPSM’s four lines of business and a dental benefit added in 2022. Our lines of business include: Medi-Cal, HealthWorx, San Mateo County Access and Care for Everyone (ACE) Program, and CareAdvantage Dual Eligible Special Needs Plans (D-SNP). Please remember that it is the provider’s responsibility to verify the member’s eligibility at the time of service as reimbursement for rendered services is subject to member’s eligibility on the date of service.
Please see the “Section 2: Customer Support” for information on how to verify member eligibility.
HPSM was originally created and began operations in 1987 to serve San Mateo County Medi-Cal beneficiaries in a managed care environment. HPSM is a County Organized Health System (COHS). California legislation and waivers to Federal Medicaid laws allow HPSM to be the exclusive insurer of health care services for nearly all Medi-Cal beneficiaries in San Mateo County. This includes seniors and persons with disabilities.
Medi-Cal members must present their HPSM member identification card to access covered services. The State of California also issues Medi-Cal beneficiaries an ID card (BIC Card). It is always best to ask to see the member’s HPSM ID card since the identification numbers may differ. Medi-Cal members cannot be balance billed.
CareAdvantage Dual Eligible Special Needs Plans (D-SNP)
In January 2006, HPSM began a Medicare Advantage Prescription Drug Plan (MA-PD). Members must have both Medicare Part A (hospital insurance) and Part B (medical insurance) and full-scope Medi-Cal through HPSM and must live in San Mateo County. HPSM offers one MA-PD program: HPSM CareAdvantage, a Dual Eligible Special Needs Plan.
Some dual eligible members may elect to remain in Original (fee-for-service) Medicare and enroll in a Prescription Drug Plan (PDP); others may join another Medicare (MA) plan. In both cases, the member will retain his/her Medi-Cal eligibility with HPSM but will not be enrolled in CareAdvantage.
CareAdvantage members are only responsible for a prescription drug copayment per prescription which conforms to Medicare guidelines. CareAdvantage members cannot be balance billed.
HealthWorx provides low-cost health benefits for San Mateo County Public Authority In-Home Supportive Services (IHSS) Workers, San Mateo County Extra Help employees and City of San Mateo part-time employees. Eligibility for HealthWorx is determined by the employing entity.
The In-Home Supportive Services program provides domestic and personal care assistance to eligible aged or disabled persons who are at risk for institutionalization.
HealthWorx is also offered to San Mateo County Extra Help Employees. Eligibility for this program is determined by the San Mateo County Employee Benefits Division. HealthWorx for City of San Mateo part-time employees is determined by the City of San Mateo.HealthWorx members have co-payments.
San Mateo County Access and Care for Everyone (ACE) Program
San Mateo County ACE is a program available to uninsured residents of San Mateo County who are not eligible for coverage through Medicare, Medi-Cal, private insurance, or other third-party coverage. ACE is a coverage program and is not considered health insurance. Enrollment in the ACE program is processed through the San Mateo County Coverage Unit. Strict income and asset levels apply. For a complete list of clinics that provide services to ACE members, please refer to the San Mateo County ACE Participant Handbook.
Referral to other providers is only through an authorized referral process.
As part of an effort to improve oral care access, quality, and utilization, as well as lower medical cost, California passed Senate Bill (SB) 849 on June 27, 2018, authorizing a Dental Integration Program in San Mateo County. This means that dental care services will be a covered benefit under Health Plan of San Mateo Medi-Cal managed care contract. The overall goal of the program is to align oral health with overall health. There will be a formal evaluation of the program to demonstrate the benefits of integrating medical and dental services.
The program was effective January 1, 2022.
Comments and Suggestions
We welcome your feedback regarding this manual and hope that you will offer any suggestions on how we can improve either subject matter or layout. HPSM's goal is to make this manual as helpful and easy to use as possible. Please email the Provider Services Department at PSInquiries@hpsm.org if you have suggestions or comments. Please note that existing provider contracts may supersede some policies stated in this material.
- Daly City
- East Palo Alto
- El Granada
- Foster City
- Half Moon Bay
- Portola Valley
- Menlo Park
- Redwood City
- San Bruno
- San Carlos
- San Mateo
- South San Francisco
- Unincorporated Areas
Who to contact
Contracts and contract terms, credentialing and re-credentialing, value based payments and pay for performance program, provider directory information and rosters, requests for provider training.
Email PSInquiries@hpsm.org or call 650-616-2106
Care Coordination/Integrated Care Management
Care Coordination Program, complex case management, linkage with plan programs and community resources, development of a personalized care plan, and participation in interdisciplinary care team meetings.
Integrated Care Management focuses on developing an individualized plan of care which can include care coordination, complex case management and linkage with plan programs and community resources.
Claim submission, claim status, claim payment inquiries, member eligibility, provider portal account setup, balance billing resolution, provider dispute resolution, encounter data submission.
General questions, or inquiries about dental benefits and/or member care coordination.
or call 650-616-2106.
For referrals, call 650-616-1522
Grievances and Appeals
For grievances and appeals related to care and/or services received.
For grievances and appeals related to Medi-Cal pharmacy services only: Magellan Customer Service and Help Desk, 24 hours per day/seven days per week.
Health Promotion/Cultural and Linguistic Services
Interpreter services, health education information and programs.
To check member’s eligibility, visit our provider portal, call the 24-hour Automated Telephone Eligibility Verification (ATEV) line, or call an HPSM line (depending on member’s line of business).
For Medi-Cal, HealthWorx, and ACE members: check benefits, PCP selection/change, Health Insurance Premium Payment (HIPP) Program.
Call 650-616-2133 or 800-750-4776
Pharmacy Services and Prior Authorization
For Medi-Cal: Magellan Customer Service and Help Desk: 24 hours per day/7 days per week.
For CareAdvantage, HealthWorx, and ACE:Pharmacy Benefit Manager) SS&C Customer Service and 24 hours per day/ seven days per week help desk.
Contact HPSM Pharmacy Services between 8:00 am and 5:00 pm, Monday through Friday.
Provider Site and Medical Record Review, peer review, and quality improvement projects/data collection (HEDIS).
Prior authorization requests for medical services, inpatient authorizations, out-of-area authorizations, outpatient services, durable medical equipment, utilization management, referral authorizations (RAF) for specialist referrals.
To request prior authorization for medical injectable drugs and other physician administered drugs (PADs), call 650-616-2088.