Medical Management is the process of providing high quality, cost-effective, outcomes-oriented healthcare to our members using sophisticated information technology, quality, case, and utilization management services.
Population Health Management
MPC offers programs to help keep members healthy. These programs are provided as an optional benefit and you can choose to join or leave the program at any time without any impact to your benefits.
For more information about any of the programs listed below, call our Special Needs Coordinator at 443-300-7325, fax to 1-844-284-7698 Monday through Friday, or email at MBUMDMedicaidSpecialNeeds@marylandphysicianscare.com. You can also call Member Services at 1-800-953-8854.
Your PCP, specialist, or other health care provider may also suggest that you join any of these programs.
Our Case Management Department is here to help you understand and control complex health conditions. A case manager may be assigned to help you plan for and receive health care services and keep track of what services are needed and what has been provided.
Special Needs Population
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 use treatment
- Children in State Supervised care
MPC has 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.
HealthChoice members with the following special needs may also qualify for Case Management services:
- 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 use treatment
For more information about case management for special needs or request services, call our Special Needs Coordinator at 1-800-953-8854 Monday – Friday.
Substance Use Disorder Services are covered by Fee for Service Medicaid.* These services will be provided directly through the Maryland Medical Assistance Program.
*This change does not affect your MCO assignment, and MPC will continue to cover 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.
To request Substance Use Disorder Services, please contact the Behavioral Health Systems at 1-800-888-1965.
Condition Care Management Program
Our condition care management program offers support by helping members and caregivers understand and engage in maintaining their optimal health. The health conditions included in this program are:
- Coronary Artery Disease/Hypertension
- Heart Failure
Complex Care Management Program
The goal of this program is to improve the behavioral and physical health quality of life for members with chronic health conditions through assessment of needs, ongoing care monitoring, evaluation, and interventions tailored to member needs.
Catastrophic Care Management Program
The focus of this program is managing and supporting members and caregivers when the member is facing a significant, life-changing event or disease. This program also provides support to members and caregivers for members with multiple chronic conditions and comorbidities as well as serious mental illness.
This program focuses on improving transitions of care for members with chronic conditions and high utilization of medical services. This is a community-based program that helps members transition from the acute hospital to home, which will lower readmission to the hospital.
MPC focuses on keeping members healthy. That’s why we closely watch and evaluate our programs and the medical care you receive. We measure the program’s quality and safety to find out what works best. This process of determining 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.
Utilization Management is a way to evaluate health care services for medical necessity. This includes care such as outpatient and home care services, pharmacy services, and inpatient hospital services.
Some health care services and medications may require Prior Authorization (PA). This is when your provider requests a service or drug that requires us to give our approval before you can get the services. Your provider is responsible for getting the PA and cannot bill you when they fail to do so.
- Utilization Management decision-making is based only on the appropriateness of the care and 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 denials.
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.
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. 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.