ISSUE 2 / SUMMER 2025
The Benefit of HEDIS
HEDIS® (Healthcare Effectiveness Data and Information Set) is a valuable tool for healthcare providers, helping them understand their performance and improve care for their patients. By understanding the HEDIS measures and incorporating them into daily practice, providers can identify and address care gaps and ensure they are meeting the standards set by the National Committee for Quality Assurance (NCQA).
Understanding Performance and Identifying Gaps:
- HEDIS measures provide a standardized way to assess the quality of care delivered by health plans and, by extension, the providers within those plans.
- By tracking HEDIS measures, providers can identify areas where they are excelling and areas where they need to improve.
- This allows for more targeted quality improvement efforts, focusing on areas where patients' outcomes can be most positively impacted.
Improving Patient Outcomes and Engagement:
- HEDIS measures often focus on specific areas of care, such as chronic condition management, preventive care, and access to care.
- By actively addressing these areas, providers can improve patient outcomes, promote better health literacy, and encourage patient engagement in their care plans.
Through HEDIS, MPC is accountable for the timeliness and quality of healthcare services delivered to its diverse membership. MPC reviews HEDIS rates on an ongoing basis and continually looks for ways to improve. It is an important part of our commitment to providing access to high-quality and appropriate care for our members. MPC makes HEDIS gaps-in-care reports available on the provider portal and provides HEDIS Tip Sheets on the provider website to assist practices with identifying HEDIS measures to engage members in care.
Access to Care Management
Members with serious health conditions like asthma, diabetes, sickle cell disease, HIV/AIDS, and heart failure often need help managing their care. An MPC Care Manager can assist with this. Care managers are trained nurses and practitioners who act as advocates, coordinators, organizers, and communicators. They support you, your staff, your patients, and their caregivers to ensure high quality and cost-effective outcomes.
Roles of a Care Manager:
- They represent the member's needs and preferences.
- They organize care and services.
- They provide a link between the members, their primary care physician, family, and other healthcare providers like physical therapists and specialists.
Benefits:
- Care managers help members understand the importance of following their treatment plans.
- They explain the risks of not adhering to the provider's instructions.
Providers can directly refer members to care management by emailing our Special Needs Coordinator at MPCSNC@mpcmedicaid.com. You can also call 1-800-953-8854 for more information about what is offered by MPC Care Management.
What is Cultural Competence?
Training Yourself in Cultural Competency
“Cultural competence is the ability to attend to the culturally diverse backgrounds of patients, providing person-centered care, and reducing health disparities.” This includes being able to recognize the diversity between and within cultures, being able to do a self-assessment, and being willing to adapt your behaviors and practices.
Practitioners can begin promoting cultural competence by completing cultural competency training. MPC offers quick access to these training resources and encourages all providers to participate in cultural competency training. Several training resources are provided on the MPC website at https://www.marylandphysicianscare.com/providers/cultural-competency-training/. Detailed information such as a link to the resource, topic covered, length, cost, and certification or CEU offered is included for each training resource. Some examples of the training offered include:
- Cultural and linguistic competency in medical practice.
- Strategies to promote self-awareness about attitudes, beliefs, biases, and behaviors that may influence clinical care.
- Conscious and unconscious bias in healthcare.
- How to effectively communicate with patients with limited English proficiency and cultural differences.
- Understanding the health needs of the LGBTQ+ population.
Sources: Rethinking Cultural Competence: Shifting to Cultural Humility - PMC
MPC Correct Coding Corner:
- Please notify Maryland Physicians Care (MPC) of any additional location-specific NPI2 information.
- Reminder - Please cooperate fully with all MPC and Maryland Department of Health (MDH) quality audits. It is a contractual requirement. Please submit complete medical records that demonstrate regulatory compliance. This includes prompt cooperation with scheduling audit reviews with independent auditors on behalf of MDH or with MPC; and promptly mailing in medical records.
- Please refer to laboratories and providers that are in the MPC network or seek prior authorization before referring to an out-of-network provider.
- Certain medications are subject to prior authorization before they can be dispensed. Please contact the MPC Pharmacy UM Department at 1-888-258-8250 to confirm the coverage status of a medication.
- Reminder – Supporting clinical documentation is required for ALL pharmacy prior authorization requests. Failure to provide complete clinical documentation with the pharmacy prior authorization form may result in a denial.
- Claims denied for inactive ePREP must be resubmitted to MPC, once the ePREP is reactivated for the date of service, to get reimbursed. Resubmitted claims must be submitted with frequency code 1 and timely filing requirements as well as all other claims edits will apply.
- To obtain a complete copy of Practitioner’s Credentialing Rights, contact MPC’s Provider Credentialing Department at 1-800-953-8854 or visit MPC Practitioners Credentialing Rights.
MPC Pharmacy: UM – Electronic Prior Authorization (ePA) Documentation
MPC administers the prior authorization review process for pharmacy benefit medications. This includes self-administered medications obtained by MPC members at their retail pharmacy location. MPC has identified an electronic prior authorization (ePA) submission issue across our provider network. MPC frequently receives ePA requests without clinical documentation to support the treatment. Please remind your staff to double-check that the criteria is completed and recent supporting clinical documentation is attached before submitting the request in the ePA system. MPC requires completed criteria and recent supporting clinical documentation for ALL prior authorization requests. Failure to supply required documents will delay the prior authorization review process and result in a denial. Please continue to complete prior authorization requests via the electronic prior authorization (ePA) process or via fax (1-833-896-0656) using our template forms found on our website here.
Preventive and Clinical Practice Guidelines
Maryland Physicians Care (MPC) encourages you to become familiar with its Preventive and Clinical Practice Guidelines. For the most up-to-date version of our preventive and clinical practice guidelines, please visit:
https://www.marylandphysicianscare.com/providers/resources/#provider-practice-guidelines.
MPC adopts preventive and clinical practice guidelines based on the health needs of our membership and opportunities for improvement identified as part of the quality improvement (QI) program. Guidelines are available for preventive services, as well as for the management of chronic diseases, to assist in developing treatment plans for members and to help them make healthcare decisions. MPC evaluates providers’ adherence to the guidelines at least annually, primarily by monitoring relevant HEDIS measures.
Migraines & Headaches
Migraines are often overlooked, but they can affect daily life.
Many people may think they are due to stress or a normal part of life. Some may not realize they have migraines. About 12% of the people in the United States experience migraines.
Researchers are unsure of the exact causes of migraines. They may be related to genetics or changes in the brain. Migraines can be triggered by things such as stress, weather changes, sleep, or medication. It is important to help patients identify what triggers their migraines.
To help patients manage migraines when they occur, consider the following tips:
- Rest in a quiet, dark space to reduce light and noise.
- Stay hydrated, as dehydration can trigger migraines.
- Place a cold compress on the forehead or neck.
When patients are provided with education and resources to understand how to manage their migraines, it can make a huge difference. This can help patients have fewer and less severe migraines and improve their quality of life. We encourage you to fill out a Health Education Request form if you have a patient who could benefit from tailored education and resources.
The 7 Cs of Communication
Effective communication is vital to maintaining an open and trusting provider/patient relationship. The 7 Cs of Communication can help. The 7 Cs is a checklist of communication skills to help improve communication.
Communication Skills include:
- Clear goals and purpose
- Concise and to-the-point messaging
- Concrete details
- Correct and accurate messaging
- Coherent messaging with a logical flow
- Complete with the identification of any needed actions
- Courteous and friendly
You can explore more on this topic by accessing the full article at The 7 Cs of Communication - Revolution Learning and Development Ltd
Help Your Patients Keep Their Medicaid Coverage With MPC!
Maryland Medicaid requires members to renew their coverage.
Your patients must renew their coverage with Maryland Health Connection this year to keep their health insurance benefits. Patients can renew their insurance by:
- GOING ONLINE to Maryland’s Health Connection at https://marylandhealthconnection.gov/checkin
- CALLING Maryland’s Health Connection’s Customer Service at 1-855-642-8572
- VISITING MPC’s website at com/renew-membership
REMIND your patients to take these very important steps to keep their MPC coverage.
For more information to assist your patients, please visit the MDH website at https://health.maryland.gov/mmcp/Pages/home.aspx.
Heat-Related Illnesses
As the seasons change, so does the temperature. The temperature rises during the summer, and the risk of heat-related illnesses largely increases. This is a major health concern for people of all ages.
During patient visits, remember to discuss risks and share ways to prevent heat-related illness. This is especially important for patients who may be at higher risk due to health conditions and lifestyle. When the body is unable to cool itself down properly, illnesses related to heat occur. Heat exhaustion and heat stroke are the most serious and need immediate attention.
Everyone can protect themselves from heat-related illnesses by:
- Drinking enough water to stay hydrated throughout the day.
- Avoiding being outdoors during the hottest part of the day.
- Seeking shade or air conditioning when available.
- Wearing lightweight and loose-fitting clothing.
- Not leaving pets, children, or individuals in a car alone.
- Staying connected, check on friends, family, and neighbors, and ask them to do the same.
Bringing awareness to patients and members of the community can help prevent heat-related illnesses. By taking precautions and knowing symptoms, everyone can enjoy summer and be safe!
Appointment Accessibility Surveys
Did you know that Maryland Physicians Care (MPC) and Maryland Department of Health conduct Appointment Accessibility Surveys? Are your patients able to obtain services when they are needed? Accessibility is key to member care and treatment outcomes.
MPC follows the accessibility requirements set forth by applicable regulatory and accrediting agencies. We monitor compliance with these standards and use the results of monitoring to ensure adequate appointment availability and reduce the unnecessary use of emergency rooms.
Please review the appointment availability standards below. The appointment accessibility standards below are found in the Provider Manual and for your ease, available as a handout/staff training tool from your designated Provider Relations Representative.
Referrals and MPC
Please note that MPC does not require referrals for specialist care.
Enroll in ePREP
Are you enrolled in the electronic Provider Revalidation and Enrollment Portal (ePREP)? ePREP is a requirement for Maryland Medicaid providers. It is a one-stop shop for provider enrollment, re-enrollment, revalidation, information updates, and demographic changes. Please ensure you are enrolled and that your information is consistently kept up to date. Providers who do not enroll or have out-of-date information may not be paid for services to Maryland Medicaid recipients. Review these tips (.pdf) for getting started and for additional resources. Enroll or update your information at eprep.maryland.health.gov.
Keep Us Informed
MPC needs to be notified if your practice is unable to accept new members. It is important that we have accurate information in our provider directory as members use the directory to select practitioners. By providing updated information, you can assist MPC in providing the best care we can for our members. It is also important for us to know if you plan to move, change phone numbers, or change your network status. Call 1-800-953-8854 to update or verify your contact information or status. You can also check your information on our secure provider portal. Please let us know at least 30 days before you expect a change to your information.
HELP PREVENT
FRAUD AND ABUSE
PLEASE REPORT FRAUD AND ABUSE by calling MPC’s Compliance Hotline at 1-866-781-6403 or online by clicking below:
Visit Our Website
Find information on:
- Quality Improvement Programs
- Population Health Management Programs
- Care Management Programs
- Health & Wellness Programs
- Clinical Practice Guidelines
- Utilization Management, including decision-making criteria, affirmative statement, and staff availability
- Pharmacy and Prescription Drug Management
- Benefits and Coverage
- Member Rights and Responsibilities
- Protected Health Information Use and Disclosure
- Provider Manual
- Member Handbook
- Provider Directory
- Credentialing Rights
WHO TO CALL
