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 Share Health Choice Statewide 153K Members 20.1% Market share Allegany and Garrett Counties 17K Members 94% Market share PAC Enrollment Statewide 13K Members 23% Market share Allegany and Garrett Counties 1,013 Members 67% 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 Measures Well Child Visit 3-6 Postpartum Care SSI Adults SSI Children Appropriate MEDS for Asthma (Combined) Cervical Cancer Screen 21-64 Lead Screening 12 and 23 Months Diabetic Eye Exams Immunizations (Combo3) Adolescent Well Care Visit Pay for Performance Maryland Physicians Care (“MPC”) has a Pay-forPerformance Program (“P4P”) which pays out annually to PCP groups that demonstrate high clinical quality 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. 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 Source HIPAA Compliant Website Prior Authorization Search Tool 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 wellbeing 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 18 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. 19 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 @ 866-710-1447 2. 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.abovehealt h.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 Care Attn:Claims PO Box 61778 Phoenix, AZ 85082-1778 Prior Auth Tips Provide 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 Information Provider 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 Care Attn: Claims Resubmission P.O. Box 61778 Phoenix, AZ 85082-1778 Appeals Address: Maryland Physicians Care Attn: Appeals 509 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?