MARYLAND PHYSICIANS CARE

November 16, 2012

Who We Are

Maryland Physicians Care (“MPC”) is a

Statewide Maryland Medicaid MCO owned by

• Western Maryland Health System

• Meritus Health

• Maryland General Health System

• St. Agnes HealthCare

Who We Are

MPC serves enrollees in

•Maryland's HealthChoice (HC) Program

•Primary Adult Care (PAC) Program

Enrollment and Market ShareHealth Choice

Statewide 153K Members20.1% Market share

Allegany and Garrett Counties 17K Members94% Market share

PAC EnrollmentStatewide

13K Members 23% Market share

Allegany and Garrett Counties1,013 Members67% Market share

HEDIS Measures (Healthcare Effectiveness Data Information Set)

HEDIS measures are reported annually on:• Effectiveness of Care• Access/Availability of Care• Satisfaction with the Experience of Care• Healthcare Plan Stability• Use of Service• Healthcare Plan Description Information• Cost of Care• Informed Healthcare Choices

2012 HEDIS Target MeasuresWell Child Visit 3-6Postpartum CareSSI AdultsSSI ChildrenAppropriate MEDS for Asthma (Combined)Cervical Cancer Screen 21-64Lead Screening 12 and 23 MonthsDiabetic Eye Exams Immunizations (Combo3)Adolescent Well Care Visit

Pay for Performance

The P4P measurement criteria is – Compatible with MPC’s core mission– Consistent with HEDIS and Department of Health

and Mental Hygiene Measurement criteria

– Seeks to align incentives.

Maryland Physicians Care (“MPC”) has a Pay-for-Performance Program (“P4P”) which pays out annually to PCP groups that demonstrate high clinical quality

CY 2012 Pay for Performance Criteria• Adolescent Well Care (Pediatrics, Family Practice)• Well Child 3-6 (Pediatrics, Family Practice)• Lead Screening* (Pediatrics, Family Practice)• Immunizations (Combo 3) (Pediatrics, Family

Practice)• Appropriate Meds for Asthma (Internal Medicine,

Family Practice & Pediatrics)• Diabetic Eye (Internal Medicine, Family Practice)• Cervical Cancer Screening (Internal Medicine,

Family Practice)• Postpartum Care (Obstetrics, Family Practice)• Timeliness of Prenatal Care (Obstetrics, Family

Practice)

*State of MD specifications instead of NCQA HEDIS specifications

My MPC SourceHIPAA Compliant Website

Prior Authorization Search Tool

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Overview

• Healthy Groove – Take Steps To Live Well is a program brought to you by Maryland Physicians Care (MPC) that helps Marylanders take control of their health and well-being by encouraging healthy habits.

• Through grassroots outreach and community advocacy across Maryland, we show simple steps for adults and children ways to: – Eat smarter– Be more active– Schedule and keep regular checkups and screening

appointments

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About the Events

• Events in communities across western, central and capital regions of Maryland

• Communities are encouraged to get their healthy groove on with:– Free food, music, giveaways and health screenings*– Free healthy and fun activities such as Nintendo Wii™,

jump rope and hula hoop contests

*Activities and screenings will vary by event.

Healthy Groove RV

www.MarylandPhysiciansCare.com

The following information can be found on our website:

•Various Forms

•Provider Manual

•Current Drug Formulary

•Search the directory of participating providers

•Access to our Secure HIPAA Compliant Website

Member Eligibility Member eligibility can be checked several ways:

1. Call EVS @ 866-710-14472. Log onto EVS at:

https://encrypt.emdhealthchoice.org/emedicaid/_Portal/provWelcome.jsp

3. Log on to MPC’s Secure HIPAA compliant web portal at: https://MarylandPhysiciansCare.abovehealth.com

Claims Tips• Fill out claim form completely including NPI #• Timely filing limit for original submissions is 180

days from the date of service• Use valid codes• Send claim to proper address:

Maryland Physicians CareAttn:Claims

PO Box 61778Phoenix, AZ 85082-1778

Prior Auth TipsProvide the following:

•Member information•Clinical note/explanation of medical necessity•Diagnosis and procedure codes•Date(s) of Service•When faxing use a cover sheet with correct phone & fax numbers for your practice

•Fax to MPC at 800-953-8856•For unscheduled admits fax to: 800-385-4169

Contact InformationProvider Relations• 1-800-953-8854

Prior Authorization • Monday – Friday 8:00am – 5:00pm• 1-800-953-8854 • 1-800-953-8856 (fax) • Secure HIPAA Compliant Website Link:

https://MarylandPhysiciansCare.abovehealth.com/

Contact Information

Claims Inquiry • 1-800-953-8854 • Secure HIPAA Compliant Website Link:

https://MarylandPhysiciansCare.abovehealth.com/

Appeals Inquiry • 1-800-953-8854 • Fax: 1-866-831-0790• Email: mpc.appeals@marylandphysicianscare.com• Basic appeals status should be checked by calling

the claims inquiry number listed above

Contact Information Claims Resubmission Address:

Maryland Physicians CareAttn: Claims Resubmission

P.O. Box 61778 Phoenix, AZ 85082-1778

Appeals Address:Maryland Physicians Care

Attn: Appeals509 Progress Dr.

Linthicum, MD 21090

Contact Information

Special Needs Coordinator for Case Management Services• 1-800-953-8854

HEDIS Coordinator• Roger Yates• 410-401-9493 – Direct line

Questions?