This is a reminder of the Health Plan of San Mateo’s (HPSM) policies regarding rebilling claims, corrected claims, and provider dispute resolutions.
Rebilling Claims
Providers can rebill when HPSM denies a claim or service line because of incorrect information supplied on the claim form. Most denied claims can be rebilled as a new claim when the claim is submitted in a timely manner. Rebilling claims is recommended for the fastest turnaround and requires the least amount of administrative effort.
Examples of rebilled claims:
Lack of required information (e.g., NDC, primary insurance information, rendering NPI, modifiers, medical records/invoice, tooth number, and HIPPS codes).
Invalid data (e.g., ICD-10 codes or sets, invalid modifier for the service/item).
Corrected Claims
Providers can update or correct claims using the Claims Correction Request Form to modify a previously submitted claim line that has already been processed. Be sure to only submit corrections or updates after receiving the final disposition of the claim in question. Find HPSM’s claims correction form here: https://www.hpsm.org/docs/default-source/provider-forms/claim_correction_request_form.pdf
Examples of corrections requiring the use of this form:
Make changes to paid service line(s) (e.g., increase or decrease units billed).
Report overpayments (including retroactive application of share of cost deductions).
Request reimbursement for a claim or service line that was originally denied as a duplicate.
Provider Dispute Resolutions
Providers can resolve claims issues through provider dispute resolution. This process includes a written notice to HPSM requesting reconsideration of a claim or a bundled group of substantially similar claims. The process should not be used to request retroactive authorization or to correct billing errors or to modify existing authorizations. Find HPSM’s provider dispute resolution form here: https://www.hpsm.org/docs/default-source/provider-forms/provider_dispute_resolution_request_form.pdf
Examples include:
Claims believed to be inappropriately denied, adjusted, or contested.
Billing determination or other contract dispute.
Disagreement with a request for reimbursement of an overpayment of a claim.
If a claim has been underpaid.
A procedure was denied as inclusive to another procedure in error.
Underpayments including directed payments (Proposition 56).
Utilization management decisions once a service has been provided.
Please refer to section 5 of HPSM’s Provider Manual for more information: https://www.hpsm.org/provider/resources/manual/provider-disputes
Direct any questions to HPSM Provider Services at PSInquiries@hpsm.org.