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Medical Management

We focus on keeping our members healthy. That’s why we closely watch and evaluate our programs and the medical care you receive. We measure their quality and safety to find out what works best. This process of figuring out how to improve your care is called the Quality Improvement Program. It helps us find areas where we can be better. Plus, it helps us improve your health.

Our Case Management Department is here to help you understand and control complex health conditions. Case managers and care coordinators can help Monday through Friday during normal business hours. A case manager may be assigned to help you plan for and receive health care services. The case manager also keeps track of what services are needed and what has been provided.

HealthChoice members with special needs may also qualify for case management:

Your PCP, specialist or other health care provider may also suggest that you join the program. Because it’s an opt-in program, you can choose to join or leave the program at any time without any impact to your benefits.

For more information about case management or to request services, call our Special Needs Coordinator at 1-443-713-4650 or fax to 1-844-284-7698.

We offer disease management programs that can help you better manage your health. These programs educate you on your disease and give you tips on how to stay healthy. If you are an adult over the age of 18 and have asthma or diabetes, we can help you.

Through the disease management program, you can get information to read and the names and phone numbers of resources who can help you manage your illness. We'll work with your doctor to come up with a care plan that is just right for you. The care plan will help you meet your goals and manage your illness.

It's your choice to participate in a disease management program.

You can join by calling our Special Needs Coordinator at 1-800-953-8854 or by email at MBU-MDMedicaidSpecialNeeds@marylandphysicianscare.com.

Your PCP, specialist, or other health care providers may also suggest that you join the program. Because it's an opt-in program, you can choose to join or leave the program at any time without any impact to your benefits.

HealthChoice members with other special needs may also qualify for case management:

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

For more information about case management, call toll-free 1-800-953-8854.

Special needs populations
The state has named certain groups as needing special support from the MCO. These groups are called “special needs populations” and include:

  • Children with special health care needs
  • Adults or children with a physical disability
  • Adults or children with a developmental disability
  • Pregnant women and women who have just given birth
  • Adults and children who are homeless
  • Adults and children with HIV/AIDS
  • Adults and children with a need for substance abuse treatment
  • Children in State‑Supervised care

We have a process to let you know if you are in a special needs population. If you have a question about your special needs, contact our Member Services department at 1‑800‑953‑8854.

Managed Care Organizations no longer cover recipients for Substance Use Disorder Services.  These services will be provided directly through the Maryland Medical Assistance Program.

To request Substance Use Disorder Services please contact the Behavioral Health Systems, etc. by calling 1-800-888-1965.

Please note, this change does not affect your MCO assignment and Maryland Physicians Care (MPC) will continue to cover you for all other HealthChoice services.  If you have any questions or concerns about your coverage under MPC, please call Member Services at 1-800-953-8854.

Concurrent review is 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. Our inpatient concurrent review process has multiple steps to reach a decision. The initial process can be done over the phone, by fax for in hospital admissions

Additionally, Maryland Physicians Care would like to remind you of our affirmation statement regarding incentives:

  • Utilization Management decision-making is based only on the appropriateness of care and the service being provided
  • Maryland Physicians Care 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

For more information about Utilization Management, please call 1‑800‑953‑8854, then follow the prompts. Staff is 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 1-877-535-0591 or phone 1-800-953-8854 and following prompts to the UM department and leaving a voice message. Communications received after normal business hours are returned the next business day. Communications after midnight M-F are returned the same business day. 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, free of charge, for members to discuss utilization management issues. MPC requires utilization management staff to identify themselves by name, title and organization when initiating or returning calls regarding UM issues.