ISSUE 4 / WINTER 2024
MPC Pharmacy: Utilization Management Update
Effective October 1, 2024, MPC has taken back the prior authorization review process for pharmacy benefit medications. This includes self-administered medications obtained by MPC members at their retail pharmacy location. MPC requires completed criteria and clinical documentation to be provided for every prior authorization to support the requested treatment. Failure to supply required documents will delay the prior authorization review process. 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.
This pharmacy team is not responsible for the review of medical benefit medications (administered by a healthcare provider) or Hepatitis C medications. Please continue to fax prior authorization requests for these medications to the MPC UM team at 1-800-953-8856.
Flu Vaccine
Preventative care for members is essential. The flu vaccine is one of the most effective ways to protect members, their families, and the community. The flu is different each season and can affect everyone differently: it can lead to hospitalization or even death. The flu can last a couple of days or result in something more serious, like pneumonia, bronchitis, sinus or ear infections, or chronic conditions becoming worse.
The flu vaccine is created to protect against the most common and severe strains of influenza. Antibodies develop in the body two weeks after the flu shot; these antibodies provide protection against the flu. When a large portion of the population is vaccinated, the spread of the virus is reduced. This is helpful for individuals who are not able to be vaccinated due to severe allergies or compromised immune systems.
If your patients have not had their flu vaccine, share this link with them for basic information: Flu Shot – Maryland Physicians Care. If patients are hesitant to take the flu vaccine, here are some facts to share:
- The flu vaccine cannot give you the flu virus.
- Annual flu vaccines are made specifically for the upcoming season’s expected flu strain. The flu virus changes and different strains circulate; therefore, the flu shot is needed each year.
- The flu vaccine lowers one’s risk of getting the flu by 40% to 60%, per the CDC.
- The CDC recommends everyone six months or older have the flu vaccine; however, there are some health-related exceptions.
CRISP – A Vital Tool for Improving Continuity of Care & Member Satisfaction
The Chesapeake Regional Information System for our Patients (CRISP) is the state-designated health information exchange (HIE) for Maryland. CRISP clinical data is available through the CRISP portal at no cost to clinical staff. It is a way of instantly sharing health information among doctors’ offices, hospitals, laboratories, radiology centers, and other healthcare organizations. CRISP allows organizations to provide safer, timelier, and more efficient patient-centered care. Clinical data from participants can be reviewed at the point of care.
Features include:
- Secure single sign-on.
- No-cost and near real-time clinical information.
- Up-to-date patient demographic data, allowing for easier patient outreach.
- Health records and images, including histories and physicals, discharge summaries, lab data, and radiology data.
- Care team information to help ensure coordination with all entities that have a relationship with a patient — this may include primary care providers, managed care organizations, and care management programs in which the patient is enrolled.
- Alerts that indicate if a care plan is available on the CRISP Health Records portal.
- Patient Care Snapshot, which provides information about interactions with the healthcare system, including emergency, inpatient, and outpatient environments — this can help identify gaps in care or provide an alert to overuse of emergency services.
- Encounter Notification Service (ENS) to alert providers when patients present to the emergency room or are hospitalized, allowing for coordination of care and prompt follow-up after discharge.
Using CRISP improves continuity of care by providing you with information from other care team participants. It can also improve member satisfaction ratings. The annual Member Satisfaction Survey includes a question related to how informed your provider seemed about healthcare received from other providers.
MPC strongly recommends you use CRISP in your day-to-day practice to improve health outcomes and enhance the patient experience. For more information on CRISP, visit https://crisphealth.org/ or call 1-833-580-4646.
Go to https://crisphealth.org/resources/training-materials/ for resources and training materials.
MPC Correct Coding Corner
HIGH-COST DRUG PRIOR AUTHORIZATION REQUIREMENT CLARIFICATION
Maryland’s Department of Health instituted a risk mitigation policy, effective January 1, 2021, to protect the HealthChoice program from utilization fluctuations related to very high-cost drugs. The policy covered both physician-administered drugs and retail pharmacy drugs, which have an expected annual cost of over $400,000. For CY 2024, the policy has been updated to include drugs with an annual cost of over $500,000. The specific drugs are found at https://www.marylandphysicianscare.com/wp- content/uploads/2023/10/High-Cost-Low-Volume-Drug-Risk-Mitigation-RX.PA_.014.MPC-Final.pdf. The list of drugs is subject to change during the year if a new drug receives FDA approval and is a covered Medicaid benefit with an expected annual cost of over $500,000.
PLEASE NOTE THAT PRIOR AUTHORIZATION IS REQUIRED FOR THESE VERY HIGH-COST DRUGS REGARDLESS OF PLACE OF SERVICE.
THIS MEANS THAT EVEN IF YOU HAVE AUTHORIZATION FOR INPATIENT ADMISSION OR HOSPITAL OUTPATIENT SERVICES, ANY DRUG ON THIS LIST WILL REQUIRE SPECIFIC AUTHORIZATION FOR THAT MEDICATION PRIOR TO ADMINISTRATION.
List of High-Volume Drugs Requiring Prior Authorization (PDF)
MPC Language Profile
As a statewide Maryland Medicaid MCO, MPC completed a language profile in August 2024 that provides insight into the many languages spoken throughout our service area. You can find the language profile on our website at the bottom of the page at https://www.marylandphysicianscare.com/members/news-and-events/annual-notice-to-maryland-physicians-care-members/. MPC identified English and 42 additional languages/language groupings within the State of Maryland. In addition to English, 39 languages are considered threshold languages, spoken by 1,000 persons or 5% of the population.
Quality-certified oral interpreter services are available for all languages through MPC’s language line vendor. You can access these services by calling our Customer Service line at 1-800-953-8854 or TTY: 1-800-735-2258 during normal business hours.
MPC also uses the language profile to determine the threshold languages for written translation of vital information provided to our members. This service is provided by quality-certified translation vendors. You can access these services by calling our Customer Service line at 1-800-953-8854. If you have an MPC member in your office who needs assistance with oral translation, please call us at 1-800-953-8854 and request interpreter services.
Urgent vs Expedited Appeal Reminder
An expedited/urgent request for an appeal determination is a request in which waiting for a decision under the standard timeframe could place the member’s life, health, or ability to regain maximum function in serious jeopardy.
If a member is currently admitted to a hospital, is inpatient, and has not yet been discharged, the member’s appeal may be considered expedited or urgent.
Providers must ensure that documents or fax cover sheets submitted to support routine requests are not marked with the words expedited, urgent, stat, or any other words implying an emergency unless the medical condition of the member meets the definition of expedited or urgent.
A valid expedited/urgent request is determined within 72 hours.
Updated Codes to Sudden and Serious Code List
Please note that MPC_Providers-ER_Sudden_and_Serious_List_ad11012024-1.pdf has been updated and shared on our website under Provider Resources (Billing and Claims section). This list includes ICD-10 codes designating an emergency room visit that requires immediate medical attention, which will automatically adjudicate hospital claims. Newly added codes will go into effect for ER claims with dates of service from November 1, 2024, forward.
Maryland Department of Health has extended telehealth services approved during the PHE through June 2025.
Increasing Perinatal Engagement
As a provider, you are often the first to engage our prenatal members. MPC has robust, comprehensive programs to support expectant and new mothers who navigate the services they need throughout the pre-and postpartum period. Care Management and care coordination programs assist members not only with the coordination of healthcare services but also with overcoming social determinants of care. MPC also offers a free Pacify App that connects members to Case Managers, Doula Services, and Lactation Consultants. More info can be found here, along with additional free programs. Check out the health education programs available on the MPC website at https://www.marylandphysicianscare.com/members/health-and-wellness/pregnancy/ in addition to information on the following services available to pre- and postnatal members:
- Home Visiting Services: provides support to pregnant women during pregnancy and childbirth, as well as support for parents and children during the postpartum period and up to two or three years of age. Home visiting services include prenatal home visits, postpartum home visits, and infant home visits. Members also have access to Doula support services!
- Doula Support Services: provides emotional and physical support to members before, during, and after pregnancy and childbirth. Visits are often in the member’s home.
- Maternal Opioid Misuse (MOM) Program: provides Care Management to address gaps in care for pregnant and postpartum members with opioid use disorder (OUD). Benefits continue for one year following the end of the pregnancy.
For more information about pre-and postnatal care or services available within your county, please visit the MPC’s Pregnancy-Related Support Services site.
Providers can also request Doula Services for a member by emailing MPCSNC@MPCmedicaid.com or calling 443-300-7325.
Pharmacy Benefit Coverage
Maryland Physicians Care is committed to delivering a cost-effective and inclusive medication formulary for our membership. We utilize a Preferred Drug List (PDL) that provides an overview of the medications we cover and details the utilization management requirements we have implemented for our formulary. The procedures for prior authorization, step therapy, quantity limits, and exclusions are highlighted in the PDL.
Reference links for medications that are carved out through Maryland Medical Assistance have been updated. In addition, a section on copayment requirements has been added. The most up-to-date version of our PDL is listed here: For Providers -> Approved Drug Benefits. The section also includes monthly formulary change updates and formulary recommendations for asthma controller medications and HIV medication management.
For any questions regarding pharmacy prior authorizations or requests for a printed copy of our PDL, please call 1-800-953-8854.
Availability of UM Criteria
To make Utilization Management (UM) decisions, MPC uses nationally recognized, evidence-based criteria that are applied based on the needs of individual members and characteristics of the local delivery system. Medical review criteria used include:
- Criteria required by applicable state or federal regulatory agencies
- Applicable InterQual Criteria as the primary decision support for most medical diagnoses and conditions
- MPC Clinical Policy Guidelines
The UM decision-making criteria are available upon receiving a denial. If you would like a copy of the criteria, please contact MPC’s Utilization Department at 1-800-953-8854 and follow the prompts to the Customer Service Department.
Managing Complex Care
Members who have high-risk, complex, or catastrophic conditions, including asthma, diabetes, sickle cell disease, HIV or AIDS, and congestive heart failure, may find it difficult to manage care on their own. At Maryland Physicians Care, Care Managers may be able to assist.
Care Managers are there to advocate, coordinate, organize, and communicate. They are trained nurses and practitioners providing quality and cost-effective outcomes as they support the provider and patient, including staff and caregivers.
The Care Manager will connect the MPC member with the healthcare team as a communication link between the member and his or her primary care physician.
The Care Manager will also act as the communication link between the MPC member, the member’s family, his or her primary care physician, and other healthcare providers if needed. Care Managers help the member to understand the benefits of their treatment plan and the consequences of not following the plan outlined by the physician.
Care Managers are available to help with the following:
- Non-compliant members
- New diagnoses
- Complex multiple comorbidities
Physicians may send referrals to the Special Needs Coordinator:
Email: MPCSNC@mpcmedicaid.com
Toll-Free: 1-800-953-8854 or 443-300-7325
Fax: 1-844-284-7698
2024 MEMBER SATISFACTION RESULTS ARE AVAILABLE!
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey is an anonymous survey that asks health plan members about their experience with their healthcare, including their experience with the care and service provided by their providers.
Physicians and office staff are critical drivers of performance on the survey. The 2024 CAHPS® survey results for both children and adults are available on the website at https://www.marylandphysicianscare.com/quality-improvement/. Provider-specific results are not available as the survey is anonymous. However, if you would like additional details or have questions about the survey or results, please contact Customer Service at 1-800-953-8854 and ask for the Quality Management Department.
Discussing a Denial with MPC’s Medical Director
If a request for service is denied due to lack of medical necessity, the requesting provider can request to speak with an MPC Medical Director to conduct a Peer-to-Peer (P2P). The intent of the P2P is to discuss the denial reason(s) with the ordering clinician or attending physician.
To request a P2P regarding a denial, please call 410-412-8297 and leave the following information:
- Member name
- Member DOB
- Authorization number (if known)
- Caller’s name and contact information
- Provider name (clinician to perform P2P)
- Provider phone number
- Provider’s available dates and time(s)*
*Please note that MPC attempts to accommodate the provider’s availability, but if the provider’s availability is more than three business days from the date of the request, the provider must file an appeal.
MPC must receive the P2P request within two business days of the initial notification of the denial. MPC has three business days to respond to P2P requests.
If the MPC Medical Director returns the P2P request and is required to leave a message, the provider has two business days to return the call, or the denial will be upheld, and the provider will need to file an appeal.
For pharmacy services or medications, please contact the following for P2P requests:
- MPC Pharmacy at 1-888-258-8250 for routine and maintenance drugs.
- MPC P2P Line at 410-412-8297 for high-cost medication, Hep C, HIV/AIDs, and drugs administered by a clinician.
For services reviewed and denied by ESS (Evolent Specialty Services – formerly National Imaging Associates, Inc.), please contact ESS for P2P questions at 1-800-424-4836.
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/checkin
- 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.
Family Planning Benefits
Family planning benefits are health and wellness services designed to help individuals and couples make informed choices regarding reproductive health, family size, and when to have children. Providers should have time-specific appointments in their schedule for family planning and members scheduled within ten (10) days of their request.
Maryland Physicians Care covers comprehensive family planning services for our members, such as:
- Office visits for family planning services.
- Laboratory tests, including pap smears.
- Oral contraceptives must allow a 12-month supply to be dispensed for refills.
- FDA-approved contraceptive devices, methods, and supplies.
- Immediate postpartum insertion of IUDs.
- Emergency contraceptives and condoms without a prescription.
- Voluntary sterilization: however, this procedure is not a self-referral. MPC members must be 21 years of age and use an in-network provider or have prior authorization to use out-of-network care.
Many pregnant members will be enrolled in Medicaid only during pregnancy and postpartum. This provides full benefits to these members during pregnancy and for one year after delivery as they will be enrolled into the Family Planning Waiver Program automatically.
- During the first prenatal visit for all Medicaid patients, the Maryland Department of Health (MDH) requires a Maryland Prenatal Risk Assessment (MPRA) to be completed. This assessment is used to support our pregnant members. The form must be completed and faxed within 10 days to the Local Health Department (LHD) in the county where the woman resides.
- The HCPC billing code for completion of an MPRA and development of the plan of care is H1000.
- Providers are reimbursed $40.00 for the completion of the MPRA and H1000 plan of care.
It is important to empower the individual to make choices that align with their health needs, family plans, and life circumstances.
Self-Service Options Available
There are many time-saving self-service options available to providers on MPC’s website and portal. These tools assist with identifying member needs and supporting your office’s administrative functions, such as submitting and checking claims, authorizations, and appeals. Be sure you are registered to use the secure online web portal to:
- Review member panel redetermination dates occurring within the next 90 days
- Review gaps in care reports
- Easily check patient eligibility
- View, manage, and download your patient list
- View claims
- View and submit service authorizations
- Communicate with us through secure messaging
- Maintain multiple providers on one account
- Control website access for your office
Other provider resources available on the MPC website:
- Provider billing guidance
- Appeals submission
- Appeal status search
- Electronic funds transfer guidance
- Operational updates
- Searchable drug formulary
- Searchable prior authorization requirements
- Download the provider manual
- Learn about MPC’s diabetes prevention program
- View pregnancy-related support services
- View Maryland Health Kids Preventive Health Schedule
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.