ISSUE 3 / FALL 2024
New Pharmacy Benefits Manager
Effective October 1, 2024, Maryland Physicians Care (MPC) will change to a new retail pharmacy benefit manager (PBM), CVS Caremark. When MPC transitions to CVS Caremark on October 1, 2024, MPC Pharmacy team will perform the Prior Authorization (PA) process for retail pharmacy benefit medications and prescriber peer-to-peer reviews. CVS Caremark will not perform these functions for MPC.
All PA reviews for pharmacy benefit medications (ePA/fax/telephonic) will be reviewed by MPC Pharmacy team by submitting requests to MPC via:
- fax (833) 896-0656 or
- phone (888) 258-8250.
Existing electronic prior authorization (ePA) processes will remain the same.
There will be no immediate impact to the formulary as MPC will continue to utilize the current preferred drug list during the transition to CVS Caremark. There will be no changes to medications that are processed under the PBM or medical benefit during the transition. All MPC members will receive a new ID card reflecting the new PBM and processing information for CVS Caremark. There should be minimal disruption to the pharmacy network access with the new PBM transition. Any member impacted by pharmacy distribution will receive notice prior to the transition offering assistance to change their pharmacy.
Please call MPC Customer Service with any questions at 800-953-8854.
Help Us Help Members Find You
It is important that MPC has information about you and your practice that is complete and accurate for the provider directory, as well as for payment and credentialing purposes. If you have not already done so, please update our records to include languages spoken, race, and ethnicity. This provides information frequently requested by members.
Please help us keep the directory accurate. By supplying updated information, you assist MPC in keeping the provider directory accurate so members can select providers that are best suited for them either geographically or perhaps because they speak a certain language.
It is also important for us to know if you plan to move, change phone numbers, or change your network status. Call 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 MPC know at least 30 days before you expect a change to your information.
Overview of Utilization Management
Utilization Management (UM) is one way that MPC monitors the medical necessity and cost-effectiveness of the services our members receive. Participating and nonparticipating health professionals, hospitals, and other providers must comply with MPC’s prior authorization (PA) and concurrent review (CCR) policies and procedures. Noncompliance with these policies may result in a delay or denial of reimbursement.
PA determination timeframes are mandated by the Maryland Department of Health. If all the necessary clinical information is received with the request, decisions are made within 2 business days and no more than 14 calendar days when additional information is required. All PA requests must be submitted on the MPC Prior Authorization Form, which can be located at https://www.marylandphysicianscare.com/providers/prior-authorization/.
The CCR function provides a way to evaluate admissions while a member is hospitalized. Admissions are reviewed for medical necessity, and continuing services are evaluated for the appropriate use of inpatient medical resources. Services subject to CCR include but are not limited to those provided in acute and specialty hospitals, rehabilitation facilities, and skilled nursing facilities, including inpatient hospice care.
To ensure a timely response to your UM request, submit all clinical information required with your request and fax it to the applicable number below:
- PA for scheduled Inpatient and Outpatient Services and Transplants @ 800-953-8856
- Inpatient Admission Notification @ 800-385-4169
- CCR Clinical Information @ 877-535-0591
- Post Discharge Services Request @ 833-424-8013
Staff can receive inbound calls on UM concerns after normal business hours. Providers should fax requests to the appropriate number. They can also call 800-953-8854 and follow the prompts for Authorization/Concurrent Review and leave a message. All communication after midnight Monday—Friday will be contacted on the same business day.
For more information on Utilization Management, please call 800-953-8854 and follow the prompts. Our staff is available eight (8) hours daily during business hours for inbound collect or toll-free calls. Language aid is available free of charge. Maryland Physicians Care provides members TDD/TTY (Telecommunication Device for Deaf/Teletypewriter) services if needed at 800-735-2258.
Updating ePREP
Maryland Medicaid’s electronic Provider Revalidation and Enrollment Portal (ePREP) is a one-stop shop for provider enrollment, re-enrollment, revalidation, information updates, and demographic changes. Your information must be consistently kept up to date. Providers without enrollment or out-of-date information may not be paid for services to Maryland Medicaid recipients. The ePREP Call Center phone number is (844) 463-7768 and is available 9 am – 5 pm ET, Monday – Friday. Enroll or update your information here. All Medicaid providers must revalidate with Maryland Medicaid at least every five years. To revalidate in ePREP, Maryland Medicaid will send a notice in the mail to prompt the provider to enter ePREP and submit a specific revalidation application.
MPC Correct Coding Corner
- 3D Mammograms: Following the updated recommendation by the U.S. Preventive Services Task Force, effective August 1, 2024, MPC reimburses covered members for 3-D screening and diagnostic mammograms. Prior authorization is not required.
- Specialty Care: Maryland Physicians Care does not require referrals for specialist care.
- Maryland Prenatal Risk Assessment (MPRA): The Maryland Department of Health requires that MPRA forms be completed by providers during the first prenatal visit and that a copy of the completed form be faxed within 10 days to the Local Health Department. Providers are reimbursed $40.00 for completing the MPRA form when billed under HCPC billing code H1000. Only one H1000 will be reimbursed per pregnancy.
Provider Reimbursement Notice:
Please be aware that the MPC base rate for Evaluation & Management and Durable Medical Equipment codes are based on the Maryland Department of Health (MDH) Medicaid fee-for-service reimbursement. As the MDH fee-for-service reimbursement increases or decreases, so will the MPC base rate change. Please note that the most recent MDH fee-for-service reimbursement has decreased due to Maryland State budgetary constraints.
2024 Member Satisfaction with PCP and Specialty Care Results
Each quarter, MPC surveys a random sample of its members to determine their satisfaction with their primary care and specialty care providers. The survey scores on a scale from one through five, with one equal to least satisfied and five equal to most satisfied. MPC sets a goal of 4.6 for member satisfaction with network providers.
Physicians and office staff are critical drivers of performance on the survey. Results for the first and second quarter of 2024 are as follows:
Member Pulse Survey
Comments from members specifically relating to their providers in the second quarter were that they felt discriminated against because of the type of insurance they had and that communication with their providers could be better.
Provider-specific results are not available as the survey is anonymous. However, if you would like additional details about the Member Pulse Survey or the results, please contact Customer Service at 800-953-8854 and ask for the Quality Management Department.
For tips on how to reduce or eliminate the perception of discrimination, and to improve communication with members, please take one or more of the FREE Cultural Competency trainings provided via the MPC website: https://www.marylandphysicianscare.com/providers/cultural-competency-training/. CEU’s and/or certificates of completion are available for some of the trainings.
Special Needs CM Referral
Referrals to Care Management provide added assistance to our members. For information on HIV Care, Pre- and Post-Natal Care, and other Special Needs Populations, please visit the HealthChoice Provider Manual on the MPC website.
The following information is required when sending a referral:
- Member Name, DOB, and Medicaid Number
- Reason for the referral
- Best phone number to reach you
The following question is not required, yet helpful:
- Is the member aware of the referral submission?
Please email, call, or fax referral information to the Special Needs Coordinator:
- Email: MPCSNC@mpcmedicaid.com
- Toll-Free: 800-953-8854 or 443-300-7325
- Fax: 844-284-7698
Member Rights and Responsibilities
Members have rights and responsibilities that cover their treatment, privacy, and access to information. We have highlighted a few below.
Member rights include but are not limited to the following:
- Receive healthcare and services that are culturally competent and free from discrimination.
- Be treated with respect to their dignity and privacy.
- Receive information on treatment options and alternatives, regardless of cost or benefit coverage, in a manner they can understand.
- Participate in decisions regarding their healthcare, including the right to refuse treatment.
- Request and receive a copy of their medical records and request that they be amended or corrected.
Member responsibilities include but are not limited to the following:
- Be on time for appointments and notify providers as soon as possible if they need to cancel an appointment.
- Show their membership card at every appointment and never allow anyone else to use their card.
- Provide the MCO and their providers with accurate health information to provide proper care.
Please read the full Rights and Responsibilities statement on Page 7 in the Provider Manual or directly here on our website.
Pharmacy Update
The management of opioid medications and access to these treatments remains a high priority for MPC. Through formulary management, opioid medications and quantity limits are assessed. Please note that existing prior authorization requirements and quantity limits remain in effect for the opioid therapeutic category. Below are formulary preferred opioids, which may also be found on the preferred drug list.
Provider Support with Breast Cancer Screenings
Breast cancer is the most common cancer in women. Early detection with effective screening is important in reducing breast cancer mortality rates. Screenings help with finding and diagnosing breast cancer early. When found during screenings, the cancer is likely to be smaller and easier to treat.
The role of a healthcare provider is to promote and support breast cancer screenings and provide patients with the proper education. Routine screenings help detect cancer before symptoms appear and can result in better outcomes. Be sure to create a personalized assessment of your patient, identify family history, note changes to their breast if they self-report, and other health concerns. Keep up to date with the current breast cancer screening guidelines and be aware of scheduling options and any local resources that offer mammograms or other screenings.
Supporting patients is more than providing education, guidelines, and resources. A supportive environment is needed as well. Be aware of language and cultural barriers, provide education materials in multiple languages, and utilize bilingual staff as interpreters when needed. This provides cultural sensitivity in communication, and the patient is more willing to take in the information. Create a safe environment, allowing the patient to feel comfortable sharing their concerns and feelings and have an open discussion regarding breast cancer and the screenings they need. Lastly, remember to follow up with patients; they trust you as their provider. Create a system to inform patients of abnormal or normal results and provide them with next steps.
There are multiple layers when supporting patients with the information they need on breast cancer screenings. However, taking these steps helps women understand the risks and benefits of screening and improve their outcomes by ensuring they have the proper support.
Cultural Competency Training
Cultural Competency Training is a perfect way to learn more about how to improve and increase the support, the environment, the communication between you and the patient, and the patient’s adherence to your recommendations/instructions. Please click here to view FREE trainings specific for providers.
Children’s Vision and Visual Perception
Every year, a child’s vision becomes stronger, and their eyes continue to develop as they learn. If a child has issues with their vision, it is important it is treated early. The issues they are having could impact the way they learn, their behavior, and their overall health. Routine eye exams are needed to keep a child’s eyes healthy.
Visual perception plays a role in a child’s vision health. It is the brain’s ability to understand and make sense of what they see. It helps the child recognize, organize, and interpret their surroundings, allowing them to understand and respond daily.
With good visual perceptual skills, children can recognize letters and objects and notice similarities and differences between them. They can complete puzzles, do reading and writing activities, dress themselves, and more. If a child is unable to complete their everyday tasks, it may affect their development and confidence.
There are ways to support children who have difficulties with visual perception. At home, encourage parents to engage with the child in activities like identifying objects by touch, coloring, or playing a game of Memory. Vision therapy will help children train their eyes and brain to work together with specific exercises and activities.
It is important to ensure vision is a priority during office visits with our pediatric patients. Vision plays a significant role in a child’s overall development and health. Taking steps to promote and advocate vision health will create awareness of the importance of eye health for everyone.
New Musculoskeletal (MSK) Surgery Management Program
Effective October 1, 2024, MPC will be expanding our partnership with Evolent Specialty Services (formerly National Imaging Associates, Inc.) by adding a new Musculoskeletal (MSK) Surgery Management program.
The MSK program will include prior authorization for non-emergent hip, knee, shoulder, lumbar, and cervical spine surgeries for MPC members. The decision to implement this program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services. Notification letters have been mailed, and educational webinars have been scheduled with dates starting September 12, 2024. Please contact 800-953-8854 for more information regarding these webinars.
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://www.marylandhealthconnection.gov/
- CALLING Maryland’s Health Connection’s Customer Service at 855-642-8572
- VISITING MPC’s website at mpcMedicaid.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.
HELP PREVENT
FRAUD AND ABUSE
MPC needs providers’ help to prevent fraud and abuse! We encourage you to report anything suspicious. Fraud and abuse occur when someone gives false information to receive healthcare benefits and/or services. Examples of fraud and abuse include:
- Someone using an ID card that does not belong to them.
- Under-reporting income and insurance or resources and assets.
- Billing for services or supplies that were not provided.
- Providing unsolicited supplies to beneficiaries.
- Misrepresenting a diagnosis, a beneficiary’s identity, the service provided, or other facts to justify payment.
- Prescribing or providing excessive or unnecessary tests and services.
- Selling prescription medications or making changes to a written prescription.
It is important to note that reporting fraud and abuse can be done without the fear of reprisal. You do not need to give us your name or contact information to report fraud and abuse, but if you do, we will keep it confidential. It is important that you give us as much information as you can because it will help us do a complete and thorough investigation. Reporting fraud and abuse can be done through:
- CALLING MPC’s Compliance Hotline at 866-781-6403 and leave a detailed message.
- GOING ONLINE at Fraud & Abuse – Maryland Physicians Care to complete the Fraud and Abuse Form.
- WRITING to the Compliance Officer at MPC, 1201 Winterson Road, 4th Floor, Linthicum Heights, MD 21090
Fraud and abuse are against the law. MPC reports all suspected incidences of fraud and/or abuse to the Maryland Department of Health, Office of Inspector General for further investigation, which can result in criminal penalties.
VISIT OUR WEBSITE
to find helpful 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
If you do not have internet service, you can reach us by phone (numbers listed in “Who to Call” – below) for more information.
WHO TO CALL
MARYLAND HEALTHY SMILES DENTAL PROGRAM
855-934-9812
PUBLIC MENTAL HEALTH SERVICES
800-888-1965
SUPERIOR VISION
800-428-8789
UTILIZATION MANAGEMENT
800-953-8854
CASE MANAGEMENT
800-953-8854
HEALTH EDUCATION REQUESTS
800-953-8854
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. We also need to know if you plan to move, change phone numbers, or change your network status. Call 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.