Doctors Referral Express
Provider Training Guide

 Chapter 1. Product Overview

The Health Plan of San Joaquin is pleased to introduce Doctors’ Referral Express (DRE), an Internet-based Utilization Management tool for our providers.  Doctor’s Referral Express provides quick, easy and secure online authorization entry, request review, clinical guidelines, eligibility verification, and claim/encounter lookup.

Providers can search authorization requests that were referred to/by the provider.  Referral requests are submitted directly to the HPSJ Utilization Management Nurses for quick review.  DRE saves time and resources by eliminating callbacks due to incomplete or illegible referral requests.  DRE automatically routes online requests to the appropriate HPSJ nurse for review.  Providers are immediately notified when an authorization request has been approved.  Requests can be viewed to determine their status in the authorization process.  Provider and their staff are allowed to see only the referral requests that they submit.

DRE provides several informational membership lookup capabilities.  The provider may validate member eligibility; review their patient’s claim/encounter and referral history, and lookup the patient’s prescription history.  DRE also links the patient with a benefit matrix explaining covered healthcare benefits and the conditions for accessing the benefits.  These features empower providers to review their patient’s history and plan the most appropriate course of treatment.

DRE also provides you with reports specific to your practice such as the Provider Report Card as well as all the Provider Alerts sent out by our Provider Relations Department.  PCP’s also have the ability to download a copy of their current Membership Roster.

Integrated into DRE is the ability to search Milliman & Robertson, Inc., Healthcare Management Guidelinesä .  The guidelines help providers identify treatment protocols that may lead to the best treatment scenario for their patients.

Each provider may obtain access to his/her private online environment by calling HPSJ Provider Services at (209) 942-6340.  HPSJ providers will be issued a personal identifier and password to gain entry into the secure site.  The Internet Web site interfaces with Microsoft Internet Explorer 5.5 or later using the same 128-bit encryption security that most banks and financial institutions are using.   The Health Plan of San Joaquin offers these services free of charge in an effort to facilitate the best possible care with minimal provider effort.

It provides a connectivity link between the physicians, facilities and utilization management organizations.  It provides communication between physicians, ancillary services, provider and membership databases and the claims server via the Internet.  This process provides an automated link from the UM organization to the providers, facilities and the claims system improving communication, reducing administrative costs and improving the authorization process.