Submit a Claims Dispute or Appeal
HPSM network provider disputes
Providers have the right to dispute all claims that HPSM has denied, adjusted or potentially underpaid. (Exception- CA Contracted Authorization Denied [pre service]- Submit as an appeal and Non-Contracted CareAdvantage appeals – see below)
- To dispute individual claims, complete the Provider Dispute Resolution Request Form
- To dispute a bundled group of substantially similar claims, complete the Provider Dispute Resolution Supplemental Form
- To dispute HPSM’s requests for reimbursement of over payment on claims, fill out one of the above forms (depending on whether it concerns an individual claim or bundled claims).
Claims Dispute Forms
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.
Provider Dispute Resolution forms may be submitted by fax or mail:
- Fax: 650-829-2051
- Mail: Health Plan of San Mateo
Attn: Provider Disputes
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080
Non-Contracted CareAdvantage Provider Disputes/Appeals
CareAdvantage non-contracted appeals must be submitted within 65 calendar days from the date of receiving notification (Remittance Advice) of HPSM’s claim action. Providers must sign and submit a Waiver of Liability verifying that they relinquish the right to collect payment from the member in order for HPSM to process the dispute.
If a waiver is not submitted, HPSM is required to send the dispute to the Medicare-contracted Independent Review Entity (IRE), which will issue the final dispute decision.
Non-Contracted providers who want to submit an Appeal of a denied claim must submit the appeal and a Waiver of Liability to the Grievance and Appeals Department.
The following are examples of appeals:
- Benefit/Frequency Limits Exhausted
- Medical Necessity
- Eligibility
- Non-covered Service
- Erroneous denial reason
- Bundled Codes
CareAdvantage Provider Waiver of Liability
Note: For claims corrections, see Rebill, Update or Correct Claims
Appeals may be submitted by phone, fax or mail:
- Phone:
- CareAdvantage members: Call the CareAdvantage Unit at 1-866-880-0606 (toll-free) or 650-616-2174
- Medi-Cal members, HealthWorx members and San Mateo County ACE participants: Call Member Services at 1-800-750-4776 (toll-free) or 650-616-2133
- Fax: 650-829-2002
- Mail: Health Plan of San Mateo
Attn: Grievance and Appeals
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080
Medi-Cal members, if your appeal is about a pharmacy or medicine issue, you will need to file it with Medi-Cal Rx directly.