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: [email protected]• 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?
