1. MARYLAND PHYSICIANS CARE
November 16, 2012
Introduction
Thank you Erika Berg and AAHAM for inviting me to this session. I hope you find the next few minute helpful

2. Who We Are
Maryland Physicians Care (“MPC”) is a Statewide Maryland Medicaid MCO owned by
Western Maryland Health System
Meritus Health
Maryland General Health System
St. Agnes HealthCare

3. Who We Are MPC serves enrollees in
Maryland's HealthChoice (HC) Program
Primary Adult Care (PAC) Program

4. Enrollment and Market Share
Health Choice
Statewide
153K Members
20.1% Market share
Allegany and Garrett Counties
17K Members
94% Market share
PAC Enrollment
13K Members
23% Market share
1,013 Members
67% Market share
As of March 2012

5. HEDIS Measures (Healthcare Effectiveness Data Information Set)
HEDIS measures are reported annually on:
Effectiveness of Care
Access/Availability of Care
Satisfaction with the Experience of Care
Healthcare Plan Stability
Use of Service
Healthcare Plan Description Information
Cost of Care
Informed Healthcare Choices
HEDIS is directed by NCQA (National Commission for Quality Assurance)

6. 2012 HEDIS Target Measures Well Child Visit 3-6 Postpartum Care
SSI Adults
SSI Children
Appropriate MEDS for Asthma (Combined)
Cervical Cancer Screen 21-64
Lead Screening 12 and 23 Months
Diabetic Eye Exams
Immunizations (Combo3)
Adolescent Well Care Visit
If you have any questions you can contact our HEDIS coordinator – Roger Yates who’s contact information is listed in the back of the presentation.

7. Pay for Performance The P4P measurement criteria is
Maryland Physicians Care (“MPC”) has a Pay-for-
Performance Program (“P4P”) which pays out annually to PCP groups that demonstrate high clinical quality
The P4P measurement criteria is
Compatible with MPC’s core mission
Consistent with HEDIS and Department of Health and Mental Hygiene Measurement criteria
Seeks to align incentives.

8. CY 2012 Pay for Performance Criteria
Adolescent Well Care (Pediatrics, Family Practice)
Well Child 3-6 (Pediatrics, Family Practice)
Lead Screening* (Pediatrics, Family Practice)
Immunizations (Combo 3) (Pediatrics, Family Practice)
Appropriate Meds for Asthma (Internal Medicine, Family Practice & Pediatrics)
Diabetic Eye (Internal Medicine, Family Practice)
Cervical Cancer Screening (Internal Medicine, Family Practice)
Postpartum Care (Obstetrics, Family Practice)
Timeliness of Prenatal Care (Obstetrics, Family Practice)
*State of MD specifications instead of NCQA HEDIS specifications

9. My MPC Source HIPAA Compliant Website

10. Prior Authorization Search Tool

18. Overview
Healthy Groove – Take Steps To Live Well is a program brought to you by Maryland Physicians Care (MPC) that helps Marylanders take control of their health and well-being by encouraging healthy habits.
Through grassroots outreach and community advocacy across Maryland, we show simple steps for adults and children ways to:
Eat smarter
Be more active
Schedule and keep regular checkups and screening appointments
This is a program that is starting into it’s fourth year with MPC. We use Healthy Groove at local community health fairs to raise awareness of the benefits of living a healthy lifestyle. 18

19. About the Events
Events in communities across western, central and capital regions of Maryland
Communities are encouraged to get their healthy groove on with:
Free food, music, giveaways and health screenings*
Free healthy and fun activities such as Nintendo Wii™, jump rope and hula hoop contests
*Activities and screenings will vary by event. 19

20. Healthy Groove RV

21. The following information can be found on our website:
The following information can be found on our website:
Various Forms
Provider Manual
Current Drug Formulary
Search the directory of participating providers
Access to our Secure HIPAA Compliant Website
Our website will soon be changing. You will still be able to access all of this information we are changing the format to make it more user friendly

22. Member Eligibility Member eligibility can be checked several ways:
Call
Log onto EVS at:
Log on to MPC’s Secure HIPAA compliant web portal at:

23. Maryland Physicians Care
Claims Tips
Fill out claim form completely including NPI #
Timely filing limit for original submissions is 180 days from the date of service
Use valid codes
Send claim to proper address:
Maryland Physicians Care
Attn:Claims
PO Box 61778
Phoenix, AZ

24. Provide the following:
Prior Auth Tips
Provide the following:
Member information
Clinical note/explanation of medical necessity
Diagnosis and procedure codes
Date(s) of Service
When faxing use a cover sheet with correct phone & fax numbers for your practice
Fax to MPC at
For unscheduled admits fax to:
Jenny
Please contact MPC’s Prior Authorization Department by TELEPHONE for INPATIENT EMERGENCY, URGENT or DIRECT ADMISSIONS.
Fax numbers are listed to use for non emergent requests. The website can also be used to submit non emergent requests.
Turn around time for non emergent requests are 2 days for complete requests and 7 days for incomplete requests.
For tertiary care referrals the following academic medical centers participate with MPC – WVU, UMMS, JHH

25. Contact Information
Provider Relations
Prior Authorization
Monday – Friday 8:00am – 5:00pm
(fax)
Secure HIPAA Compliant Website Link:

26. Contact Information
Claims Inquiry
Secure HIPAA Compliant Website Link:
Appeals Inquiry
Fax:
Basic appeals status should be checked by calling the claims inquiry number listed above

27. Contact Information
Claims Resubmission Address:
Maryland Physicians Care
Attn: Claims Resubmission
P.O. Box 61778
Phoenix, AZ
Appeals Address:
Attn: Appeals
509 Progress Dr.
Linthicum, MD
Corrected Claims need to be submitted as Resubmissions not as appeals.

28. Contact Information
Special Needs Coordinator for Case Management Services
HEDIS Coordinator
Roger Yates
– Direct line

29. Questions?
Questions?