Provider Alerts

Health Plan has made some adjustments to the Retrospective Review Protocol to ensure our members receive care without delay. The protocol listed below is effective immediately.

Retrospective Protocol

A network provider or practitioner may request retrospective authorization for covered services rendered to a member when the request is made 1) within thirty (30) calendar days after the initial date of service, and 2) if one of the following conditions apply:

1. The Member has Other Health Coverage (OHC); or
2. The Member has a retrospective eligibility segment; or
3. The Member’s medical condition is such that the provider or practitioner is unable to verify the member’s eligibility for Medi-Cal, and/or HPSJ eligibility at the time of service; or
4. The request is for Non-Emergency Medical Transportation (NEMT) services. The request must include a completed Health Plan Physician Certification (PCS) form validating the need for this type of service.

Out-of-network/non-contracted providers are not eligible to request retrospective authorizations.

If while doing an outpatient procedure, the MD notices that another procedure is necessary but has not been authorized, it is ok to submit a retrospective authorization ASAP, but within 30 calendar days of the service being rendered.

Retrospective eligibility segment: A member without active Health Plan eligibility at the time services are rendered then becomes eligible, with the date extending retroactively and including the date of service. For example, a member not eligible with Health Plan is seen in your office January 5, 2024; DHCS then determines the member to be eligible and provides the information to Health Plan in February that the member is eligible beginning January 1, 2024.

Decision and notification requirements: All retrospective review decisions are completed within 30 Calendar Days of receipt of all information necessary to make a decision, including notification to the requesting provider and member.

Submission Request: Requests may be submitted via the Provider Portal or Fax.  When submitting a retrospective authorization request, please indicate the request is a Retrospective Review and include all clinical information demonstrating medical necessity of the request.

Please direct questions to your Provider Services Representative who will work with Utilization Management to address your questions.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-7526 (PLAN). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org