Transcript Postpartum Care (Obstetrics, Family Practice)

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
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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
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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.
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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: [email protected]
• 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?