Utilization Managment

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 reviewed for the appropriate use of inpatient medical resources. MPC’s inpatient concurrent review process contains multiple steps to complete a determination. The initial process can be done via telephone or fax, through a review of hospital electronic records or with in-hospital reviews.

To speak with someone from the UM Department please call, 1‑800‑953‑8854, then follow the prompts.  Staff are available at least eight (8) hours a day during normal business hours for inbound collect or toll-free calls regarding utilization management issues. Staff can receive inbound communication regarding UM issues after normal business hours by fax to 877-535-0591 or phone 1-800-953-8854 and following prompts to Authorization/Concurrent review and leaving a voice message. Maryland Physicians Care TDD/TTY (Telecommunications Device for the Deaf/TeleTypewriter) services are provided for members who need this service at 1-800-735-2258.  Language assistance is also available for members to discuss utilization management issues.

MPC requires utilization management staff to identify themselves by name, title and organization name; and upon request, verbally informs member; facility personnel; the attending physician and other ordering practitioners/providers of specific utilization management requirements and procedures.

Admissions to non-par facilities are reviewed for medical necessity based on MPC’s provider network ability to provide the same services.  All requests for admission to non-par facilities require prior authorization 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 who is transferred from a provider to a non-par provider must have prior approval by MPC’s medical director for the service by calling Maryland Physicians Care.  If this is not met, then the admission has the potential for denial.  Any member who is transferred from a provider to a non-par provider with prior authorization must be transferred back to a par provider as soon as is stabilized.

MPC’s chief medical officer (CMO) is responsible for directing and overseeing the inpatient concurrent review function. Concurrent review clinicians and medical directors that are qualified by training, experience and certification/licensure in accordance with state and federal regulations are responsible for carrying out the daily inpatient concurrent review operations, including timely and accurate documentation of review activities (e.g., authorizations, updates, consultations) per contractual agreements. Only an appropriately licensed health care professional may make determinations regarding the medical necessity of health care services during the course of utilization review.

Services subject to concurrent review include, but are not limited to, those provided in acute facilities, rehabilitation facilities and skilled nursing facilities. Licensed clinicians working under the direction of the CMO or designated medical director completes initial reviews of members’ admissions within 24 hours of MPC’s receipt of notification of admission. Subsequent reviews are conducted on a schedule determined by the member’s reason for admission, kind of facility and its location.  Services provided to MPC members are reviewed for appropriateness, efficiency, and timeliness.  Failure to provide services timely may result in denials for delay in service.

When a Maryland Physicians Care (MPC) member is admitted to your facility you are required to send formal notification to the Prior Authorization department within 1 business day.  Clinical information must then be sent to the Utilization Management department within 24 hours of that notification.

The following is the minimum clinical information that must be received in order for a complete medical necessity review to be performed:

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, discharge plans, including any social concerns.

The Peer to Peer process is as follows:

The attending or treating physician or the hospital physician advisor may request a peer to peer with MPC’s medical director by calling 1-800-953-8854 and following prompts to Authorization/Concurrent review.  The physician will need to leave his/her name and contact information along with the member’s name and facility name.  The MPC medical director will return the call within 24 hours.  The facility must request the peer to peer within 2 business days of initial notification of the denial.  Any clinical information provided will need to be faxed in to 877-535-0591.  If you have additional clinical information please fax it in to the concurrent review fax line prior to the peer to peer.   A determination will be provided on the log. If there are any questions, please call 800-953-8854 and follow the prompts to Authorization/Concurrent review.

Concurrent review clinicians are responsible for:

  • Identifying cases that potentially may be adverse decisions based on medical necessity during concurrent review of inpatient admissions or ongoing services
  • Reviewing potential adverse determinations with the medical director
  • If services are rendered an adverse determination:
    • Notifying the facility’s business office or other designated department of decisions to deny or terminate reimbursement within 24 hours of the decision
    • Documenting, or informing data entry staff to document, the adverse determination decision in the business application system prior authorization module

Authorization requests that do not meet criteria for the requested service, or for which there are no established medical necessity criteria, or those meeting certain administrative thresholds (e.g., high-dollar cases) will be presented to a medical director for review. The medical director conducting the review must 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 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 can be made available upon your request. Should you like to obtain a copy you can contact MPC’s Utilization Department by calling 800-953-8854 and follow the prompts to the Concurrent Review Department.

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

  • Current, applicable codes may include:
    • Current Procedural Terminology (CPT)
    • International Classification of Diseases, 9th Edition (ICD-9 AS OF 10-01-2015 THIS MUST BE ICD-10)
    • CMS (Centers for Medicare and Medicaid Services) Common Procedure Coding System (HCPCS) code
    • National Drug Code (NDC)
  • Name, date of birth, sex and identification number of the member
  • Primary care provider or treating practitioner
  • Name, address, phone and fax number and signature, if applicable, of the referring practitioner or provider
  • Name, address, phone and fax number of the consulting practitioner or provider
  • Problem/diagnosis, including the ICD-9 code  AS OF 10-01-2015 THIS MUST BE ICD-10
  • Reason for the referral
  • Presentation of supporting objective clinical information, such as clinical notes, laboratory and imaging studies, and treatment dates, as applicable for the request

Additionally, MPC would like to remind you of our affirmation statement regarding incentives:

  • UM decision-making is based only on the appropriateness of care and the 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

When a Maryland Physicians Care (MPC) member is admitted to your facility you are required to send formal notification to the Prior Authorization department within 1 business day.  Clinical information must then be sent to the Utilization Management department within 24 hours of that notification.

The following is the minimum clinical information that must be received in order for a complete medical necessity review to be performed:

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, discharge plans, including any social concerns.