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data-parent=".announcement-button" aria-label="Close Announcements" role="button"><i class="fa fa-window-close text-danger" aria-hidden="true"></i> <span class="text-danger">Close</span></a> </div> </div> </header> <main class="main-content"> <div class="container-fluid"> <div class="row"> <div class="col-12"> <div class="container-fluid-margin"> <div > <div class="sfContentBlock sf-Long-text" ><p class="plan-name">Provider Manual | Section 5</p><h1>Provider Disputes</h1></div> </div> </div> </div> <div class="col-xs-12 col-sm-4"> <div class="container container-fluid-margin"> <div class="page-navigation ml-sm-3"> <div class="accordian-menu PMS5513" role="navigation" aria-labelledby="pageNav"> <span id="pageNav"> <span class="Provider Manual">Provider Manual</span> <i href="#sideNav" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent=".accordian-menu"></i> </span> <div class="list-group panel" id="sideNav"> <a href="https://www.hpsm.org/provider/resources/manual/section-1-about-the-provider-manual" class="list-group-item strong "> Section 1: About HPSM </a> <a href="https://www.hpsm.org/provider/resources/manual/customer-support" class="list-group-item strong "> Section 2: Customer Support </a> <a href="https://www.hpsm.org/provider/resources/manual/member-complaints" class="list-group-item strong "> Section 3: Member Complaints </a> <a href="https://www.hpsm.org/provider/resources/manual/claims" class="list-group-item strong "> Section 4: Claims </a> <a href="https://www.hpsm.org/provider/resources/manual/provider-disputes" class="list-group-item strong active"> Section 5: Provider Disputes </a> <a href="https://www.hpsm.org/provider/resources/manual/ancillary-services" class="list-group-item strong "> Section 6: Ancillary Services </a> <a href="https://www.hpsm.org/provider/resources/manual/utilization-management" class="list-group-item strong "> Section 7: Utilization Management </a> <a href="https://www.hpsm.org/provider/resources/manual/provider-services" class="list-group-item strong "> Section 8: Provider Services </a> <a href="https://www.hpsm.org/provider/resources/manual/quality-improvement" class="list-group-item strong "> Section 9: Quality Improvement </a> <a href="https://www.hpsm.org/provider/resources/manual/health-education" class="list-group-item strong "> Section 10: Health Education </a> <a href="https://www.hpsm.org/provider/resources/manual/fraud-waste-and-abuse" class="list-group-item strong "> Section 11: Fraud Waste and Abuse </a> <a href="https://www.hpsm.org/provider/resources/manual/privacy" class="list-group-item strong "> Section 12: Privacy </a> </div> </div> </div> <div class="related-items ml-sm-3"> <div class="card"> <div class="sidebar"> <h3> </h3> <div > <div class="sfContentBlock sf-Long-text" ><h3><a href="d876054f-e7f9-4f09-bdcd-7d88a86cc37e" title="Provider Manual"><span class="text-primary">Download the Manual</span></a></h3><p>Please check back frequently for a newer version of the manual.</p></div> </div> <div> <div class="media"> <div class="media-left"> <span class="fa fa-file-pdf-o"> </span> </div> <div class="media-body notranslate"> <a class="sf-title" href="https://www.hpsm.org/docs/default-source/provider-manual/2025-provider-manual.pdf?sfvrsn=f35ed257_3" target="_blank">2025 Provider Manual</a> <span class="small nowrap">(2369 KB)</span> </div> </div> </div> <div > <div class="sfContentBlock sf-Long-text" ><hr></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h3>Provider Services</h3><p class="mt-3"><span class="text-navy nobreak">Toll free:</span> <span class="phone">1-833-694-7761</span> <span class="text-navy">Local:</span> <span class="phone">650-616-2106</span></p><p class="mt-3"><span class="text-navy">Fax:</span> <span class="phone">650-616-8046</span><span class="text-secondary"></span><span class="nobreak"></span></p><p class="mt-3"><span class="text-navy">Email:</span> <a href="mailto:psinquiries@hpsm.org">psinquiries@hpsm.org</a></p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h3>Claims Services</h3><p class="mt-3 mb-1">Medical and dental claims: <span class="phone">650-616-2106</span></p><p class="mt-1 mb-3"><span>Monday, Tuesday, Thursday & Friday</span> <span class="nobreak">8:00 a.m. to 5:00 p.m.</span> <span class="nobreak">(closed 12:00 p.m. to 1:00 p.m.)</span></p><p class="mt-1"><span>Wednesday</span> – 8:00 a.m. to 12:00 p.m.</p><p class="mt-3"><span class="text-navy">Email</span> <a href="mailto:ClaimsInquiries@hpsm.org">ClaimsInquiries@hpsm.org</a>.<br>Email confirmation sent by next business day</p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h3>Feedback Welcome</h3><p>We welcome your feedback on how we can improve the Provider Manual. HPSM's goal is to make this manual as helpful and easy to use as possible.</p><p>Please call the Provider Services Department at <span class="phone">650-616-2106</span> with your comments or suggestions.</p></div> </div> </div> </div> </div> </div> </div> <div class="col-xs-12 col-sm-8"> <div class="content-area container-fluid-margin"> <div > <div class="sfContentBlock sf-Long-text" ><div class="border border-light rounded py-2 px-2 w-100 mb-3"><div class="row"><div class="col-12"><p class="my-1 small">Section 5 contents</p></div><div class="col-md-6"><ol class="mt-1 small"><li><a href="#a1" data-sf-ec-immutable="">Provider Disputes</a></li><li><a href="#a2" data-sf-ec-immutable="">Updates and Claim Corrections</a></li><li><a href="#a3" data-sf-ec-immutable="">Provider Dispute Resolution</a></li><li><a href="#a4" data-sf-ec-immutable="">Time Periods for Submission</a></li></ol></div><div class="col-md-6"><ol start="5" class="mt-1 small"><li><a href="#a5" data-sf-ec-immutable="">Time Frames for Resolution</a></li><li><a href="#a6" data-sf-ec-immutable="">Non-Contracted Provider Disputes - CareAdvantage Only</a></li><li><a href="#a8" data-sf-ec-immutable="">Provider Grievances</a></li></ol></div></div></div></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h2 id="a1" style="margin-left: 30px">Provider Disputes</h2><p align="left" style="margin-left: 30px">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 by 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. </p><p style="margin-left: 30px">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 <span class="phone" style="background-color: rgba(0, 0, 0, 0); text-align: inherit; text-transform: inherit; word-spacing: normal">650-616-2106</span> <span style="background-color: rgba(0, 0, 0, 0); color: inherit; text-align: inherit; text-transform: inherit; word-spacing: normal; white-space: inherit">.</span> </p><p style="margin-left: 30px">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  “<a href="/provider/resources/manual/member-complaints"><strong>Section 3: Member Complaints.</strong></a>”</p><h2 id="a2" style="margin-left: 30px">Updates and Claim Corrections </h2><h3 style="margin-left: 30px">Corrected Claims </h3><p align="left" style="margin-left: 30px">Corrections by providers to previously submitted claims are not considered provider disputes.  Corrections can be submitted using one of the following options.</p><h3 style="margin-left: 30px">Rebill Claims  <br></h3><p align="left" style="margin-left: 30px">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. </p><p align="left" style="margin-left: 30px">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:  </p><ul style="margin-left: 30px"><li>Lack of required information (e.g., NDC, primary insurance information, rendering NPI, modifiers, medical records/invoice, and HIPPS codes). </li><li>Invalid data (e.g., ICD-10 codes or sets, invalid modifier for the service/item).</li></ul><h3 style="margin-left: 30px">How to Rebill Claims</h3><p style="margin-left: 30px">You can rebill HPSM using the same method used to submit claims. Please submit denials requesting additional documentation on paper and address to:</p><div class="ml-3" style="margin-left: 30px"><p>Health Plan of San Mateo<br>Attn: Claims Processing <br>801 Gateway Blvd., Suite 100 <br>South San Francisco, California 94080 </p></div><h3 style="margin-left: 30px">Dental Claims</h3><p style="margin-left: 30px">For dental claims, please submit denials requesting additional documentation on paper and address to:</p><div class="ml-3" style="margin-left: 30px"><p>HPSM Dental <br>PO Box 1798 <br>San Leandro, California 94577 </p></div><h3 style="margin-left: 30px">Rebill Submission Timeframes</h3><h4 style="margin-left: 30px">Medi-Cal</h4><p style="margin-left: 30px">Rebill within 6 months of service date.</p><h4 style="margin-left: 30px">CareAdvantage</h4><p style="margin-left: 30px">Within 12 months of service date</p><h4 style="margin-left: 30px">HealthWorx</h4><p style="margin-left: 30px">Within 12 months of service date </p><h3 align="left" style="margin-left: 30px">HPSM’s Claims Correction Request Form</h3><p align="left" style="margin-left: 30px">Update 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:</p><ul align="left" style="margin-left: 30px"><li>Make changes to paid service line(s).</li><li>Report overpayments (including retro application of share of cost deductions). </li><li>Request reimbursement for a claim or service line that was originally denied as a duplicate.</li></ul><h3 align="left" style="margin-left: 30px">How to Correct or Update Claims<strong> </strong></h3><ol style="margin-left: 30px"><li>Complete the Claims Correction Request Form found here: <a href="/docs/default-source/provider-forms/claim_correction_request_form.pdf?sfvrsn=6e914468_25"><strong>https://www.hpsm.org/docs/default-source/provider-forms/claim_correction_request_form.pdf</strong></a><strong> </strong></li><li>Attach a copy of the corrected claim form.</li><li>Submit the form to HPSM by fax or mail. <ol><li>Fax:  <strong><span class="phone">650-829-2051</span></strong></li><li>Mail: </li></ol></li></ol><p style="margin-left: 90px">Health Plan of San Mateo<br>Attn: Claims Processing <br>801 Gateway Blvd., Suite 100 <br>South San Francisco, California 94080 <br><br></p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h2 id="a3">Provider Dispute Resolution</h2><p>HPSM offers 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: </p><ul><li>Claims believed to be inappropriately denied, adjusted, or contested. </li><li>Resolution of a billing determination or other contract dispute. </li><li>Disagreement with a request for reimbursement of an overpayment of a claim. </li><li>If a claim has been underpaid. </li><li>A procedure was denied as inclusive to another procedure in error. </li><li>Utilization management decisions once a service has been provided.</li></ul><div class="callout callout-secondary"><p>Note: The PDR process should not be used to request retroactive authorization. Instead, retroactive authorization requests should be submitted directly to HPSM’s Health Services department.</p></div><p>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.</p><p>Providers should submit their dispute through submission of a <a title="Provider Dispute Resolution Request Form" href="/docs/default-source/provider-forms/provider_dispute_resolution_request_form.pdf?sfvrsn=def9c022_13">Provider Dispute Resolution Request Form</a>, including the following information:</p><ul><li>Provider name.</li><li>NPI billed on claim.</li><li>Provider contact information.</li><li>Identification of the disputed item, including; <ul><li>The original HPSM claim number.</li><li>Date of service.</li><li>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. </li></ul></li></ul><p>A sample of the Provider Dispute Resolution form is included in this section. The form is also available on HPSM's website at <a href="/Home"><strong>https://www.hpsm.org</strong></a><strong>.</strong> You may fax your PDR request to <span class="phone">650-829-2051</span> or if you want to print the form and send it via mail, please send your PDR to the address below: </p><div class="ml-3"><p>Health Plan of San Mateo <br>Attn: Provider Disputes <br>801 Gateway Boulevard, Suite 100 <br>South San Francisco, California 94080</p></div></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h2 id="a4">Time Periods for Submission</h2><p>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.</p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h2 id="a5">Time Frames for Resolution</h2><p></p><p>HPSM will send an acknowledgement letter to the provider within 15 working days of receipt of the dispute mail. </p><p>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 <span style="background-color: rgba(0, 0, 0, 0); color: inherit; text-align: inherit; text-transform: inherit; word-spacing: normal; white-space: inherit">“</span><a href="/provider/resources/manual/member-complaints" style="text-align: inherit; text-transform: inherit; word-spacing: normal; white-space: inherit"><strong>Section 3: Member Complaints</strong></a><span style="background-color: rgba(0, 0, 0, 0); color: inherit; text-align: inherit; text-transform: inherit; word-spacing: normal; white-space: inherit"> section of this manual.</span></p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h2 id="a6">Non-Contracted Provider Disputes <span class="small">—CareAdvantage Only</span></h2><p>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 “<a href="/provider/resources/manual/member-complaints"><strong>Section 3: Member Complaints</strong></a>.” 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. </p><p align="left">Non-Contracted providers, who want to submit a dispute regarding a payment decision, must submit the dispute through the Provider Dispute Resolution process. </p><p></p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h2 id="a8">Provider Grievances</h2><p>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 <span class="phone">650-616-2106</span>.</p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><div class="text-center mt-5"><span class="divider 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