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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.

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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.

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 in writing to:

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.

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.

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.

Guidelines and Procedures

Below you will find helpful guidelines and procedures of our health plan:

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

COLORECTAL CANCER TOOLKIT

  1. CRC Screening Promotion Toolkit Intro and Content Summary (PDF)
  2. CRC At-a-Glance for Providers and Administrators (PDF)
  3. CRC Screening Minimal Clinical Elements Summary (PDF)
  4. 80% by 2018 Fact Sheet (PDF)
  5. 80% by 2018 Pledge (PDF)
  6. Increasing CRC Screening Resource List (PDF)
  7. Provider Relations CRC Slides (PDF)
  8. Cancer Screening Patient Questionnaire (PDF)
  9. CRC Questionaire Provider Letter Template (PDF)
  10. CRC Screening Patient Reminder Letter Template (PDF)
  11. Local CRC Screening and PN Resource List (PDF)
  12. CRC Articles for Newsletters (PDF)
  13. CRC Screening Messaging for Targeted Populations (PDF)
  14. CRC Screening Promotion Toolkit Feedback Form (PDF)

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 2020-2021 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.

Stay tuned for more tip sheets!

HEDIS and VBP
AMR, BCS, CHL, CBP, CCS, CDC, CIS, IMA, Lead Screening, PPC, W30, WCV, WCC (PDF)
Women’s Care
BCS, CHL, CCS, PPC (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.

Know The Facts About Coronavirus (COVID-19)

Symptoms are flu-like, including: fever, coughing, and shortness of breath.

If you think you might have been exposed, contact your doctor immediately. You can also have a video visit with a doctor using the MyVirtualMPC app.

It is important to do everything you can to protect yourself from COVID-19.

Notice

We are currently experiencing an issue with our Post Discharge and Clinical fax numbers. Please use these alternative numbers to fax this information to us:

Concurrent Review/Clinical Information: 833-694-1487

Post Discharge Services: 833-694-1485