Quick References

Find Coronavirus Resources (PDF) to help members during this time.

Maryland Department of Health (MDH) Notices

Provider Manual

Helpful Information at Your Fingertips

Whether you are looking for information about covered services, specific treatment protocols, or how claims are handled, your MPC provider manual is a comprehensive resource.

Download

MPC Provider Manual (PDF)
- For information on how to contact MPC or submit a claim refer to our Quick Reference Guide.
HealthChoice Self-Referral and Emergency Services Manual (PDF)
Infusion Site of Care Notification

Referral Process

As an MPC Primary Care Physician (PCP) or Primary Specialist Provider (PSP), you are responsible for initiating and coordinating referrals of enrollees for medically necessary services beyond the scope of your practice. If you are a PCP, you also ensure that members you refer to specialists return to your care as soon as appropriate.

Documentation of the referral in the enrollee’s medical charts is required. Additionally, as a PCP or PSP, you should provide pertinent referral information to the participating MPC health professional to whom you refer the member.

A prenatal risk assessment form is required for obstetrics services. Please complete the form and mail or fax it to our Case Management department immediately upon confirmation of pregnancy.

If an in-network specialist is not available, we may issue a prior authorization for a referral to a noncontracted provider. Please note that a noncontracted provider will not be reimbursed without prior authorization.

Note: A prior authorization may still be required for services. Check the prior authorization grid or contact MPC for details or with any questions.

Pre-Service appeals, services have not yet been rendered or appeals where the member is in a hospital/facility are considered MEMBER APPEALS. For all other appeals, specifically Post-Service appeals, where services have been rendered, are PROVIDER APPEALS. Please fax/mail to the appropriate number/address below and complete the appropriate form, where necessary.

MEMBER PRE-SERVICE APPEAL

MPC requires a formal written request to reconsider a medical decision. Medical records should be attached. For additional information, visit Member Complaints, Grievances and Appeals.

Provider Post-Services Appeals

Maryland Physicians Care has a process regarding provider appeals as a request for a review of an action-related to claims denials. Appeals for service denials, reductions, or terminations are considered member appeals and follow the MCO member appeal process.
Complete Appeal Form

Maryland Physicians Care requires all provider appeals to be submitted electronically or in writing to:

Submit Electronically

Maryland Physicians Care

P.O. Box 1104
Portland, ME 04104

Fax: 833-656-0648

TIMEFRAMES RELATED TO THE APPEALS PROCESS

Providers have 90 business days to file an appeal from the date of claim denial. Maryland Physicians Care acknowledges provider written appeals within five business days of its receipt.
Providers are allowed 30 days from the date of Maryland Physicians Care’s appeal determination to file one subsequent level of appeal for consideration. Second-level appeals must include additional information or documentation for consideration.
Maryland Physicians Care resolves denial of payment appeals (including a second-level appeal within 90 business days of receipt of the initial appeal by Maryland Physicians Care).
Previously denied claims are paid within 30 days of the appeal decision when a claim denial is overturned.

We will not take any punitive action against a provider for utilizing our provider complaint process.

Mail or fax form and documentation:

Maryland Physicians Care

Member Appeals
PO Box 893
Portland, ME 04104

Fax: 866-831-0790

Please note that member consent is required.

Provider Practice Guidelines

Maryland Physicians Care encourages the use of Care Guidelines to ensure the delivery of quality care. For resources and information about clinical practice guidelines, preventive guidelines, and substance abuse guidelines please click on the below links.

GUIDELINES
2023 Medical Practice Guidelines (PDF)
2020 Updates to the Asthma Management Guidelines (PDF)
2023 Clinical Preventive Services Guidelines (PDF)
Childhood Lead Exposure Guidelines

COLORECTAL CANCER TOOLKIT

HEDIS Tip Library

As you may know, quality of care is measured through the Healthcare Effectiveness Data and Information Set (HEDIS). The following HEDIS Tip Sheets have been created to reflect NCQA HEDIS 2021-2022 Technical Specifications and may be used as a reference to help you increase your practice’s HEDIS rates. Please note that Maryland Physicians Care does not advise providers on which codes to use. Please always follow the State and CMS billing guidance to ensure the codes are covered prior to submission.

HEDIS
AMR, BCS, CHL, CBP, CCS, CDC, CIS, IMA, Lead Screening, PPC, W30, WCV, WCC (PDF)

NIA Announcements

Beginning January 1, 2021, National Imaging Associates, Inc. (NIA) will provide utilization management for outpatient rehabilitative and habilitative physical medicine services on behalf of Maryland Physicians Care for members 21 years and older.

For more information, review the documents linked below.