ACE Program
Billing and Payment Information for Authorized Services
As the third party administrator (TPA) for the San Mateo ACE Program, the Health Plan of San Mateo will be processing claims submitted by providers for authorized services provided to eligible ACE Participants. These are services rendered by providers under their contracts with San Mateo County and the San Mateo Medical Center (SMMC). Because this program is new and creates a new set of relationships between SMMC, HPSM, and providers contracted with SMMC, we would like to take this opportunity to explain how this program will operate. Please note that the process described below has been developed in conjunction with SMMC and according to federal guidelines for the funding.
- If you have a contract with SMMC, your office/facility will provide services to San Mateo ACE Participants by referral from a San Mateo ACE Provider. You may also need to obtain prior authorization for these services from HPSM.
- After the service is provided, you should submit a claim to HPSM. HPSM will adjudicate the claim, including checking for the authorization, and determine whether it should be paid or denied. HPSM will adjudicate claims within 30 days of receipt of a clean and authorized claim.
- You will receive notice of the adjudication decision via your regular weekly HPSM explanation of payment (EOP). However, HPSM will not release payment.
- HPSM will report to SMMC the amount due to your office/facility.
- SMMC will review the payment file and make payment accordingly. Your payment will come from SMMC. SMMC will release payment within three weeks of the EOP date. Payment delays may occur based on the status of your contract with San Mateo Medical Center.
If you have any questions or concerns about the way a claim is adjudicated or the amount adjudicated per your EOP, you may contact HPSM’s Claims Department at 650.616.2056.
If you have questions about whether your payment matches your EOP or about the timeliness of payment, you should contact SMMC’s Accounting Department at 650.573.2863. You may also contact SMMC’s Contracting Department at 650.573.2134 to discuss contract concerns.