Medical Management

Medical Management is the process of providing high quality, cost-effective, outcomes-oriented healthcare to our members using sophisticated information technology, quality, care, and utilization management services.

Population Health Management programs are offered to enrollees who need additional services and/or have special needs. These programs include Care Management, Condition Care Management, Complex Care Management, Catastrophic Care Management, and Transition Care.

Referrals to these Programs

For more information on our Care Management Programs, contact our Special Needs Coordinator by phone at 443-300-7325 or by email to MPCSNC@mpcmedicaid.com, or call 1-800-953-8854.

Referrals can be made by fax to 1-844-284-7698 or email to MPCSNC@mpcmedicaid.com.

Our population health management programs are voluntary, and all members have the option to agree or decline the service without any impact on their benefits.

Our Care Management Department assists members understand and control complex health conditions. Care management services are covered for members who need additional services or have special needs.

Special Needs Population

The state has determined the following “special needs populations” groups as needing special support from the MCO:

• Children with special health care needs
• Individuals with a physical disability
• Individuals with a developmental disability
• Pregnant and postpartum women – learn about our pregnancy program
• Individuals who are homeless
• Individuals with HIV/AIDS
• Individuals with a need for substance abuse services
• Children in State-supervised care

HealthChoice members with the following special needs may also qualify for Care Management services:

• Children with special health care needs
• People with physical and/or developmental disabilities
• Pregnant and postpartum women – learn about our pregnancy program
• People who are homeless
• People with HIV/AIDS
• People who need substance use treatment

If warranted, a care manager is assigned to an enrollee when the MCO receives the initial health screening results. You may receive a care plan when one of your members is engaged in case management.

Community health workers are available to perform home visits as necessary as part of Maryland Physicians Care Care Management Outreach Program. The representative assists the member with any access to care needs during the home visit.

The Condition Care Management Program supports the practitioner-member relationship and plan of care. It emphasizes the prevention of exacerbations and complications through evidence-based practice guidelines and evaluates clinical, member experience, and economic outcomes on an ongoing basis with the goal of improving overall health.

The Program employs a member-centric approach that helps members/caregivers understand and engage in attaining or maintaining their optimal health. The Program implements strategies to support and enhance the practitioner-member relationship to improve the quality and coordination of care delivered to the member.

The health conditions included in the Condition Care Management Program are:

• Asthma
• Coronary Artery Disease/Hypertension
• COPD
• Heart Failure
• Diabetes

The Complex Care Management Program is a system of coordinated healthcare interventions and communications for populations with conditions in which enrollee self-care efforts are significant.

Evidence-based medicine and a team approach is used to:

• Empower enrollees
• Support behavior modification
• Reduce incidence of complications
• Improve physical functioning
• Improve emotional well-being
• Support the physician/enrollee relationship
• Emphasize and reinforce use of clinical practice guidelines

The goal of the Program is to improve the behavioral and physical health outcomes and quality of life of enrollees with chronic conditions by using a multi-faceted approach to achieve the best possible therapeutic outcomes based on assessment of enrollee needs, ongoing care monitoring, evaluation, and tailored enrollee and practitioner interventions. The Program also aims to reduce hospital length of stay and lower overall costs.

The integrated Program focuses on two distinct enrollee populations:

• Enrollees that experience a catastrophic event – The focus is on managing and supporting enrollees and caregivers in instances where an enrollee experiences a significant, potentially life changing event or diagnosis, such as malignant cancer, degenerative neurological disease, respiratory failure or liver diseases, etc. Most of these enrollees are identified through the utilization management (UM) authorization process for enrollees admitted with one of the targeted conditions listed under Catastrophic Care Identification Criteria. The primary goal is to support the implementation of the enrollee’s Primary Care Physician (PCP)/Specialist treatment plan to prevent avoidable readmissions, reduce unnecessary emergency room (ER) visits, and remove barriers that may prevent the enrollee and his/her caregiver(s) from adhering to his/her treatment plan.
• Enrollees with multiple, severe, intensive conditions – Management and support is provided to enrollees and their caregivers in instances where an enrollee has multiple chronic conditions with other significant comorbidities, or significant diagnoses and barriers, such as serious mental illness, cognitive and/or functional deficits, degenerative neurological diseases, etc.

 

The Transition Care Program was developed to improve the enrollee’s experience and health outcomes as they transition along the health care continuum. By focusing on the enrollee’s transition from an acute hospitalization to home, the team hopes to lower the enrollee’s risk for readmission back to the hospital or emergency department.

The Program focuses on improving transitions of care for an enrollee population with multiple chronic conditions and high rates of utilization of medical services. This community-based program consists of a care team that may include a regional or market medical director, care advisors (CA), health educators, social workers, pharmacists, community health workers, care coordinators and program coordinators.

The Maryland Department of Health (MDH) administers a Rare and Expensive Case Management (REM) program to address the special needs of waiver-eligible individuals diagnosed with rare and expensive medical conditions. The REM program, a part of the HealthChoice Program, was developed to ensure that individuals who meet specific criteria receive high-quality, medically necessary, and timely access to health services. For additional information please see the Maryland Department of Health website at https://mmcp.health.maryland.gov/longtermcare/pages/rem-program.aspx.

 

Maryland Physicians Care is proud to introduce member benefits in diabetes prevention services. Maryland Physicians Care follows the Maryland Department of Health Diabetes Prevention Program requirements to offer Recognized National Diabetes Prevention Program provider programs to address the growing problems of prediabetes and those at-risk for type 2 diabetes.

Our Diabetes Prevention Program is offered statewide to all members, 18 – 64 years of age who have prediabetes or are at risk for type 2 diabetes but do not already have diabetes. Maryland Physicians Care is working with primary care providers to refer at-risk members to the Diabetes Prevention Program. Members are encouraged to make positive lifestyle changes such as eating healthier, reducing stress, and increasing physical activity.

Quality Improvement

Maryland Physicians Care has a Quality Management Program. This Program monitors and assesses the health care services delivered to our members. The goal of the Quality Management Program is to deliver high-quality care and services to all members.

Every year, Maryland Physicians Care measures the progress against all goals in the Quality Management Program including clinical and service activities like:

• Promoting health care safety with member and provider education.
• Establishing preventive health and clinical practice guidelines. These help members understand what kind of services they need and how often they’re needed.
• Making sure members have access to qualified health care professionals.
• Ensuring members receive appropriate preventive care. Examples of preventive care are:
  • Annual flu shots
  • Child immunizations (shots)
  • Eye tests
  • Cholesterol tests
  • Breast Cancer Screenings
  • Care for women before and after the baby is born
• Evaluating member quality of care concerns and taking action as needed.
• Conducting surveys to see if members are satisfied with the services they are receiving from their doctors.

For more information about our Quality Management Program, please contact Member Services at 1-800-953-8854.

To see a copy of our quality improvement accomplishments and goals, click here.

To see the results of our 2023 Provider Pulse Surveys please click here.

To see our 2023 PCP Satisfaction Survey results please click here.

Utilization management is one way Maryland Physicians Care monitors the medical necessity and cost effectiveness of the services our members receive. Participating and nonparticipating health professionals, hospitals, and other providers are required to comply with Maryland Physicians Care’s prior authorization and concurrent review policies and procedures. Noncompliance may result in the delay or denial of reimbursement.

For more information about utilization management, please call 1‑800‑953‑8854, then follow the prompts to the Prior Authorization Department. Staff is available at least eight hours a day during normal business hours for inbound collect or toll-free calls regarding utilization management issues. Maryland Physicians Care TDD/TTY services are provided for members who need this service at 1-800-735-2258. Language assistance is also available, free of charge, for members to discuss utilization management issues.

Staff can receive inbound communication regarding UM issues after normal business hours by faxing to the applicable number before or calling 1-800-953-8854 and following prompts to Authorization/Concurrent review and leaving a voice message. Communications received after normal business hours are returned the next business day. Communications after midnight Monday – Friday are returned the same business day.

MPC requires utilization management staff to identify themselves by name, title, and organization name. They must verbally inform members, facility personnel, attending physicians, and other ordering practitioners/providers of specific utilization management requirements and procedures upon request.

Affirmation statement regarding incentives:
MPC bases UM decision-making only on the appropriateness/medical necessity of the care and service being provided. MPC does not reward health care providers or other individuals for issuing denials of coverage or service. There are no financial incentives for UM decision-makers to encourage underutilization.

Prior Authorization requests follow the decision time frame mandated by the Maryland Department of Health. If all the necessary clinical information is received with the request, decisions are made within 2 business days and not more than 14 calendar days when additional information is required.

To ensure a timely response to your request, submit all prior authorization requests at least 14 days in advance with all required information. Prior Authorization requests must be submitted on the MPC Prior Authorization form and faxed to the applicable number below or by calling 800-953-8854 and following the prompts to the Prior Authorization Department.

Effective 4/1/21, the following Prior Authorization form will be required for all prior authorization submissions to Maryland Physicians Care.

Services Requiring Prior Authorization

All non-emergency elective hospital admissions require prior authorization (PA).

All oncology and radiation oncology services require PA and must have an Eviti Code prior to submitting the PA request. Please contact Provider Services regarding access to our current oncology and radiation oncology services vendor at www.eviti.com.

After the initial evaluation, rehabilitative and habilitative therapy services, including those rendered by Chiropractors, require PA. Services rendered in a hospital emergency department, observation unit, or inpatient unit; in an acute rehabilitation hospital; or in a skilled nursing facility do not require PA. Please contact Evolent Specialty Services (formerly known as National Imaging Associates) prior to or within 5 business days of rendering services. Evolent can be reached at www.RadMD.com or via Evolent’s call center at (800) 424-4836.

Certain non-emergent outpatient cardiac procedures require prior authorization. These services include CT/CTA, MRI/MRA, PET Scan, CCTA, Myocardial Perfusion Imaging, MUGA Scan, Stress Echocardiography, and Echocardiography (TTE/TEE). Cardiologists may receive authorizations by contacting Evolent at www.RadMD.com or via Evolent’s call center at (800) 424-4836. Approved authorizations will have a validity period of 60 days from the date of request.

PA is required for high tech radiology and non-emergent musculoskeletal procedures including outpatient, interventional spine pain management services. These authorizations are obtained through Evolent at www.RadMD.com or via Evolent’s call center at (800) 424-4836.

Maryland Physicians Care requires laboratory and radiology services to be done in free-standing (non-regulated) facilities. Authorization are required for services performed in hospital/facility (regulated) space. Certain radiology and laboratory services may require PA regardless of place of service.

Maryland Physicians Care requires all defined CMS outpatient procedures to be rendered in an Ambulatory Surgical Center (ASC). Authorization is required for services performed in hospital/facility (regulated) space. Certain procedures require PA regardless of place of service.

Outpatient hospital or facility-based surgical services may require PA.

Durable medical equipment (DME), homecare, therapy, and hospice require PA.

To see which procedures require PA, access the Pre-Auth Check tool on the Maryland Physicians Care website under the Providers section.

Laboratory – Members are to be referred to a participating free-standing laboratory provider for services not in the PCP’s/PCO’s/PSP’s contract. All laboratory services performed outside Maryland Physicians Care’s laboratory network require PA. Laboratory and certain radiology services may not be performed in a hospital setting.

Non-participating providers must obtain PA before rendering any service other than emergency services. Participating providers must obtain PA before rendering any service that is not exempt from PA requirements. Services that require PA may be denied if PA has not been obtained.

Registered network providers may perform electronic look-up of a PA through the employment of Maryland Physicians Care’s HIPAA-compliant web portal.

All elective hospital admissions require PA.

Please refer to our Prior Auth check tool to determine if other services you are requesting require PA.

• PA requests must include the following:
  • Name, date of birth, and identification number of the member
  • Gender (for gender specific procedures only)
  • Current, applicable codes which may include: Current Procedural Terminology (CPT), Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes, National Drug Code (NDC)
  • Diagnosis code: International Classification of Diseases, ICD-10 CODES
  • Name, phone and fax number of the referring/ordering practitioner or provider
  • NPI & TIN of referring/ordering practitioner or provider
  • Name, phone and fax number of the servicing practitioner or provider (place of service or facility)
  • NPI & TIN of servicing practitioner or provider
  • Reason for the request
  • Number of units requested for each code
  • Clinical information including but not limited to supporting objective clinical information, such as clinical notes, laboratory and imaging studies, and treatment dates, as applicable for the request.

** DME/DMS requests require a pricing list or invoice included with the clinical information

**Enteral Formula and Nutritional Supplement requests require the MDH Nutritional Supplement form with the clinical information (see FORMS)

**Remote Monitoring requests require the MDH Remote Monitoring form with the clinical information (see FORMS)

Authorization requests that do not meet criteria for the requested service, or for which there are no established medical necessity criteria will be presented to a medical director for review. The medical director conducting the review will have clinical expertise in treating the member’s condition or disease and must be qualified by training, experience, and certification/licensure to conduct the authorization functions in accordance with state and federal regulations.

The medical director will review the service request, the member’s need, and the clinical information presented. Using the approved criteria and the medical director’s clinical judgment, a determination to approve or deny the service will be made. Only a medical director can reduce or deny a request for service based on a medical necessity review. The UM decision-making criteria is available upon request.

All transplant services require Prior Authorization

Please submit all required clinical information via fax: 800-953-8856
Transplant Evaluation requests should include:

1. Letter of medical necessity AND appropriate PA form with a MPC Center of Excellence Facility.
2. Routine complete history and physical (including pertinent routine social history) within 6 months.
3. Basic labs (chemistries, CBC, and liver function tests) within 6 months, plus:
   1. Liver – MELD or PELD score, hepatitis serologies, imaging and biopsy as indicated.
   2. Kidney – GFR (already in routine tests) or creatinine clearance if not on dialysis.
   3. Heart – echo and cardiac catheterization results.
   4. Lung – PFT’s, imaging, and 6-minute walk test.
   5. Pancreas – BMI, C-peptide, and history of insulin treatment.
   6. Intestine/Multivisceral-no additional testing.
   7. Stem cell – most recent bone marrow biopsy as indicated.

Transplant Listing and Authorization Extension requests should include:

1. Letter of medical necessity from a transplant service physician
2. Routine complete history and physical within 6 months.
3. Basic labs (chemistries, CBC, and liver function tests) within 6 months, plus:
   1. Liver – same as above.
      Kidney – same as above plus PRA and cardiology testing/clearance.
      Heart – same as above plus exercise testing inclusive of (MVO2) and NYHA class.
      Lung – same as above.
      Pancreas – same as above.
      Intestine/Multivisceral-no additional testing
      Stem cell – same as above, plus performance score and documentation of donor identification for allogeneic stem cell.
4. Annual dental* clearance.
5. Routine health screening exams as per standards of care (mammograms, Pap, and/or colonoscopy).
6. Appropriate comorbidity testing/clearance, including cardiology.
7. Serum or Urine Drug screen results (within 90 days of request)
8. Infectious disease screening:
   1. CMV, EBV, VZV within one year unless baseline IgG antibody positive.
   2. Hepatitis A within one year, unless baseline antibody positive
   3. Hepatitis B testing within one year unless baseline surface antibody positive.
   4. Hepatitis C within one year unless baseline positive (viral load required within three months if positive).
   5. RPR within one year.
   6. HIV within one year unless baseline positive (CD4 count and viral load required within three months if positive).
   7. Toxoplasma titer for heart transplant recipients.
   8. Results of annual PPD, T-Spot, or QuantiFERON for all solid organ transplants, unless previously positive.
9. Detailed psychosocial evaluation within 6 months.
10. UNOS validation is required for transplant listing extension.
11. Continuity of care – Submit documentation validating previous listing approval plus a copy of the current UNOS listing.

*Dental Care through the Maryland Healthy Smiles Dental Program

Transplant Eval Checklist – Final

Transplant Listing Checklist – Final

The concurrent review function provides a way to evaluate admissions while a member is hospitalized. Admissions are reviewed for medical necessity, and continuing services are evaluated for the appropriate use of inpatient medical resources.

Services subject to concurrent review include but are not limited to those provided in acute and specialty hospitals, rehabilitation and skilled nursing facilities, including inpatient hospice care.

Services provided to Maryland Physicians Care members are reviewed for appropriateness, efficiency, and timeliness. Failure to provide services timely may result in denials for the delay in service.

When a Maryland Physicians Care member is admitted to a facility, the provider is required to send a formal notification to the Prior Authorization department within one business day. Clinical information must then be sent to the Utilization Management Department within 24 hours of that notification.

Participating hospitals, where an observation facility stay transitions to an inpatient admission, are required to notify Maryland Physicians Care within 24 business hours of the admission.

Admissions to non-par facilities are reviewed for medical necessity based on the ability of Maryland Physicians Care’s provider network to provide the same services. All requests for admission to non-par facilities require prior authorization (PA) by calling Maryland Physicians Care. Any member who presents to a non-par provider through the emergency room must be transferred to a par provider as soon as stabilized. Any member transferred from a provider to a non-par provider with PA must be transferred back to a par provider as soon as stabilized.

The admitting or treating provider is responsible for complying with Maryland Physicians Care’s concurrent review requirements, policies, and procedures as well as making the following information available for concurrent review:

• Name, date of birth, gender, and identification number of the member
• Current, applicable codes which may include: Current Procedural Terminology (CPT), Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes, National Drug Code (NDC)
• Diagnosis code: International Classification of Diseases, ICD-10 CODES
• Name, phone, and fax number of the referring/ordering practitioner or provider
• NPI/TIN of referring/ordering practitioner or provider
• Name, phone, and fax number of the servicing practitioner or provider (place of service)
• Reason for the referral
• Supportive objective clinical information, such as clinical notes, laboratory and imaging studies, and treatment dates, as applicable for the request
• Clinical information must be received for a complete medical necessity review to be performed. At a minimum it must include: the mode of presentation (home, ER, direct, transfer, elective); the current presenting complaints, including clinical signs and symptoms; past medical history; the working diagnosis; tests, labs, consults ordered and the results; treatment plan; medications; and discharge plans including any social concerns.

Authorization requests that do not meet criteria for the requested service, or for which there are no established medical necessity criteria are presented to a medical director for review. The medical director conducting the review have clinical expertise in treating the member’s condition or disease and are qualified by training, experience, and certification/licensure to conduct the authorization functions in accordance with state and federal regulations.

The medical director reviews the service request, the member’s need, and the clinical information presented. Using the approved criteria and the medical director’s clinical judgment, a determination to approve or deny the service is made. Only a medical director can reduce or deny a request for service based on a medical necessity review. The Utilization Management decision-making criteria is available upon request.

The Peer-to-Peer Process is available to a clinician who is rendered a preservice or concurrent medical necessity denial. The intent of the Peer-to-Peer is to discuss the denial decision with the ordering clinician or attending physician.

To request a Peer-to-Peer regarding a denial, please call 410-412-8297 and leave the following information:

• Member name
• Member DOB
• Authorization # (if known)
• Caller’s name and contact information
• Provider name (Clinician to perform P2P)
• Provider phone number
• Provider’s available dates and time(s) (Maryland Physician Care will try to accommodate the providers availability but please note that if the provider’s availability is more than 3 business days from the date of the request, the request will not be processed.)

The Peer-to-Peer request must be received by Maryland Physician Care within 2 business days of the initial notification of the denial.

Maryland Physicians Care has 3 business days to respond to Peer-to-Peer requests.

If the Maryland Physicians Care Medical Director returns the Peer-to-Peer request and leaves a message, the provider has 2 business days to return the call or the denial will be upheld and the provider will need to file an appeal.

For pharmacy services or medications reviewed by ESI (Express Scripts), please contact Express Scripts for Peer-to-Peer requests at 1-800-753-2851.

For services reviewed and denied by Evolent Specialty Services (formerly known as National Imaging Associates), please contact Evolent for Peer-to-Peer questions at 1-800-424-4836.

Medical clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures.
Medical clinical policies help identify whether services are medically necessary based on information found in:

• generally accepted standards of medical practice,
• peer-reviewed medical literature,
• government agency/program approval status,
• evidence-based guidelines and positions of leading national health professional organizations,
• views of physicians practicing in relevant clinical areas affected by the policy,
• and other available clinical information.

Maryland Physicians Care policies are applied according to member eligibility and medical necessity criteria. Policies in the Maryland Physicians Care Medical Clinical Policy Manual may have either a Maryland Physicians Care or a Evolent heading. Maryland Physicians Care utilizes InterQual® criteria for those medical technologies, procedures, or pharmaceutical treatments for which a Maryland Physicians Care medical clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool.

In addition, Maryland Physicians Care may from time-to-time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure, or treatment not addressed in the Medical Clinical Policy Manuals or InterQual® criteria is payable by Maryland Physicians Care.

MPC Clinical Policies

For MPC Medication Policies click here

Site of Service Outpatient Infusion Services