Reminder: Enhanced Provider Dispute Resolution (PDR) Process
| Date: | July 24, 2024 |
| From: | Health Plan |
| To: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Providers and Facilities |
| Type: | Educational/ Informational |
| Subject: | Reminder: Enhanced Provider Dispute Resolution (PDR) Process |
| Business: | Medi-Cal Managed Care |
On April 15, 2021, Health Plan implemented several new enhancements to the PDR process. This alert serves as a reminder to ensure each Provider Dispute Resolution (PDR) is appropriately routed for review.
Health Plan asks that you continue to follow the procedures below:
- Contracted Providers must submit a provider dispute online through the
Provider Portal/Doctors Referral Express (DRE) https://provider.hpsj.com/dre/default.aspx. - Non-Contracted Providers must mail-in provider disputes with the appropriate Health Plan PDR form (https://www.hpsj.com/provider-dispute-resolution/) to:
Attention: Claims Department
Health Plan of San Joaquin
P.O. Box 30490
Stockton, CA 95213-30490
- If you are submitting corrections on a claim, please follow the Corrected Claim submission guidelines.
- If a claim was denied as a duplicate and you feel it denied in error – before you submit a dispute – please make sure it was submitted with the appropriate documentation, modifiers, or corrected claim submission indicator.
- If a claim or claim line was denied for “supporting documentation” please submit as Correspondence with the requested information.
Note: Failure to submit the provider dispute through DRE, or on the Health Plan PDR form, will be returned for completion. This may result in a delay of processing and potentially could fall outside of the dispute processing guidelines set by the California Department of Managed Health Care (DMHC).
Reasons for a PDR Request:
- Contract Dispute: Original claim did not pay per contracted or Medi-Cal rate
- Appeal of Medical Necessity/Utilization Management Decision: Original claim denied because of a denied authorization or partial authorization
- Seeking Resolution of a Billing Determination: Do not agree with a claim or claim line denial
- Recovery Dispute: A letter was received regarding an identified overpayment, and you do not agree with the determination
- If the provider wishes to contest (Recovery Request Dispute) the notice of reimbursement of overpayment request it must be within thirty (30) working days.
- Seeking Resolution of a Supplemental Payment: Do not agree with the supplemental amount and/or denial of the supplemental payment
PDR Process Reminders:
- All provider appeals must be submitted with a completed PDR Form.
- Providers should not submit a PDR for claims that have been rejected due to billing errors. Providers should submit a corrected claim for these circumstances, https://www.hpsj.com/advice-correcting-cms-1500-claims-submissions-also-when-not-to-submit-a-dispute/ (Provider Alert, April 22, 2016) for corrected claim submission.
- Using the PDR form enables us to properly route your request, along with all supporting documentation, to the appropriate area for review.
- Submissions must include the most appropriate supporting documentation. Examples include notes (surgical/operative/office); pathology reports; medical invoices (e.g., DME or pharmaceuticals); medical record entries; etc.
- A PDR form that is not completed correctly will be returned as incomplete.
Provider/Facility may only submit a total of three (3) PDRs per claim number.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). 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
