Provider Manual

This manual contains policies and procedures relevant to providers that are contracted with HPSM. It is designed as a reference tool to assist with the administrative tasks related to accessing and providing comprehensive, effective and quality medical services to HPSM members.

Please be aware that different policies and procedures may apply depending on the program(s) with which you are contracted. Also note that existing provider contracts may supersede some policies stated in this material.

Manual updates

This manual is updated regularly as policies and procedures change. Updates and supplements will be distributed as they occur and will be available as downloadable documents from this webpage for your convenience.  

To ensure your manual has the most current information, please be sure to replace the existing pages in the manual upon receipt of any updates.  

Search the Provider Manual 

To make it easier for providers, the Provider Manual can be searched in two ways:

  1. Download the entire Provider Manual as a single PDF file and then use the find function (CTRL + F).
  2. Open individual sections from the links below. This function is good if you already know which section you need.

 Section 1 - About HPSM

  • Introduction
  • Keeping Members Healthy
  • Quality Improvement
  • HPSM website
  • Provider Manual Updates
  • Our Programs
  • Comments & Suggestions
  • Service Area
  • Who to Call

  Section 2 - Customer Support

  • Introduction
  • Member Rights & Responsibilities
  • Programs & Enrollment Information
  • Identifying HPSM Members
  • Identification Cards & Co-Payments

  Section 3 - Member Complaints

  • Introduction
  • Timeframes in the Complaint Process
  • Member Grievances
  • How to Submit a Grievance
  • Appeals & Authorization Requests
  • Filing an Appeal

  Section 4 - Claims

  • Filing a Paper Claim
  • Timelines for Claims Submission
  • Billing Tips for Claims Submission
  • Filing Electronic Claims
  • HPSM Fee Schedule
  • Payment Policies & Rules
  • Reimbursement Guidelines
  • Coordination of Benefits Billing
  • Balance Billing
  • Contacting the Claims Department

  Section 5 - Provider Disputes

  • Dispute Resolution Overview
  • Provider Grievances
  • Resolution Flow Chart
  • Resolution Request Form

  Section 6 - Ancillary Services

  • Laboratory Testing
  • Prescription Drugs
  • Quality Review
  • Pharmacy Management Programs
  • Pharmacy Network
  • Mental Health & Substance Abuse
  • Radiology & Imaging
  • Chiropractic & Acupuncture
  • Physical & Occupational Therapy
  • Speech Therapy
  • Podiatry
  • Vision Care
  • Durable Medical Equipment
  • Audiology/Hearing Aids
  • Prosthetics/Orthotics

  Section 7 - Utilization Management

  • Overview
  • Specialty Referral Process
  • Prior Authorizations
  • Care Coordination Program
  • Self-Referred Care
  • Emergency & Urgent Care
  • Long Term Care
  • Child Health & Disability Program
  • Complex Care Management
  • Care Transitions
  • Terminated Providers
  • Monitoring for Utilization
  • Review Criteria & Standards
  • Decision Support Tools
  • Appeals Process

  Section 8 - Provider Services

  • Overview
  • Credentialing & Contracting
  • Rights & Responsibilities
  • Coverage Hours & Standards
  • Trainings & Communications

  Section 9 - Quality Improvement

  • Overview
  • Site & Medical Record Review
  • HEDIS
  • Clinical Practice Guidelines
  • Quality Committees
  • Quality Improvement Projects
  • Individual Health Assessment
  • Value Based Payment Program
  • Potential Quality Issues

  Section 10 - Health Education

  • Overview
  • Physician Authority
  • Health Education Materials
  • Member Newsletter
  • Culturally & Linguistically Appropriate Services
  • Access to Interpreter Services
  • Services for Members with Disabilities

  Section 11 - Fraud Waste and Abuse

  • Introduction
  • Definitions
  • Examples of FWA
  • Reporting FWA
  • Resources

  Section 12 - Privacy

  • Introduction
  • Examples of Privacy Incidents
  • Privacy and Security Safeguards
  • Reporting Privacy Incidents
  • Resources

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.

If you have suggestions or comments, please call the Provider Services Department at 650-616-2106.