|
|
|
Billing and Payment Information (New for 2009)
Under the Consolidated ACE Program, HPSM is taking over the functions of provider contracting and payment for dates of service in 2009. These are functions were maintained by San Mateo County in 2008. Because of this change in contracting, billing and payment processes will vary based on date of service.
For dates of service in 2009:
- HPSM will solicit contracts with providers to provide services to San Mateo ACE Participants.
- Contracted providers will provide services in accordance with the referral and prior authorization rules for the San Mateo ACE Program.
- After the service is provided, providers 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 also determine appropriate payment amounts based on each provider’s contract with HPSM.
- HPSM will issue payments or other notices through an Explanation of Payment (EOP). The EOP for the San Mateo ACE line of business will be issued once a month.
Questions about claims pricing and payment should be referred to HPSM’s Claims Department at 650-616-2056.
For dates of service in 2008:
- Providers will provide services to San Mateo ACE Participants by referral from a San Mateo ACE Provider under their contracts with San Mateo County/SMMC. Prior authorization may also be required, depending on the service.
- After the service is provided, providers 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 determine appropriate payment amounts based on each provider’s contract with San Mateo County/SMMC.
- HPSM will issue notice of the adjudication decision through an Explanation of Payment (EOP). The EOP for the San Mateo ACE line of business will be issued once a month. However, HPSM will not release payment.
- HPSM will report to SMMC the amount due to each provider office/facility.
- SMMC will review the payment file and make payment accordingly. Payment will come from SMMC. SMMC will release payment within three weeks of the EOP date. Payment delays may occur based on providers’ contract status with the County/SMMC.
Questions about the way a claim is adjudicated or the amount adjudicated on an EOP should be referred to HPSM’s Claims Department at 650.616.2056. Questions about whether a payment matches an EOP or about the timeliness of payment should be referred to SMMC’s Accounting Department at 650.573.2863. Questions about contract status should be referred to SMMC’s Contracting Department at 650.573.2134.
|