Member Resources

Welcome patients! This page contains helpful resources for managing your health and navigating managed care. As always, feel free to contact us at 442-231-8101 or 657-206-8700 if you have questions or concerns.

Member Rights and Responsibilities

Members have the right to be represented by parents, guardians, family members or other conservators for those who are unable to fully participate in their treatment decisions.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Language Assistance Program Contacts

The Health Care Language Assistance Act requires insurers to establish and support language assistance programs for certain residents who have limited English proficiency. This link provides important contacts by health plan for these programs.

Advanced Health Care Directive

By creating an Advanced Health Care Directive you can let your physician, family, and friends know your health care preferences, so in the event that you become incapacitated, you can ensure that decisions are made according to your will. The forms below offer a guide to creating your Advanced Health Care Directive. If necessary, take time to speak with your healthcare professional.

Local Wellness Center

We have compassionate warm Member service staff to address your questions and concerns. Come by and say Hi and enjoy the daily wellness activities offered. Our business hours are Monday through Friday, 9:00a.m. to 5:00p.m. Our Member Service number is 442-231-8101.

Affirmative Statement

As a utilization management organization, Premier Patient Care IPA, ensures that all decisions are made based on the available medical information at the time of the request. Should a member ask to see the criteria utilized to make a medical decision; the statement below is attached to that guideline, as required by the National Committee for Quality Assurance (NCQA):

Decisions regarding requests for medical care are based on the medical necessity of the request, the appropriateness of care and service and existence of coverage. There is no monetary reward for non-approval of services. Compensation for individuals who provide utilization review services does not contain incentives, direct or indirect, for these individuals to make inappropriate review decisions.

Utilization review criteria, based on reasonable medical evidence and acceptable medical standards of practice (i.e. MCG and/or applicable health plan guidelines) are used to make decisions pertaining to the utilization of services. Review Criteria are used in conjunction with the application of professional medical judgment, which considers the needs of the individual patient and characteristics of the local delivery system. A copy of the Medical Criteria guidelines can be delivered upon request by emailing support@procaremso.com or by telephone at 657-206-8700.

Premier Patient Care IPA will use the following guidelines to make medical necessity decisions (listed in order of significance) for outpatient and inpatient on a case-by-case basis, based on the hierarchical information provided on the member’s health status:

For Medicare

A. NCD-Medicare Coverage Determinations

Federal law (e.g., National Coverage Determinations (NCD))

https://www.cms.gov/medicare-coverage-database/search.asp

B. Medicare Local Coverage Determinations (LCD)

State law/guidelines (e.g., when State requirements trump or exceed federal requirements) LCD per State

https://www.cms.gov/medicare-coverage-database/reports/local-coverage-final-lcds-state-report.aspx?stateRegion=all&contractorNumber=all&lcdStatus=all

D. Use of Nationally Evidenced Based Recognized Guidelines

In the absence of Medicare, use of nationally evidenced based recognized guidelines such as MCG (formerly Milliman Care Guidelines®) is used; with supporting documentation that other criteria in hierarchy not available and deference-guidelines and must be used in connection with the independent professional judgment of a qualified professional

https://www.molinahealthcare.com/members/common/en-US/clinicalpolicies.aspx

F. Additional Information for Consideration

In the case of no guidance from A-E, additional information that the applicable Medical Director will consider, when available, includes:    

  • Reports from peer-reviewed medical literature, from which a higher level of evidence and study quality is more strongly considered in determinations
  • Professional standards of safety and effectiveness recognized in the US for diagnosis, care, or treatment    
  • Nationally recognized drug compendia resources such as Facts & Comparisons®, DRUGDEX®, and The National Comprehensive Cancer Network® (NCCN®) Guidelines    
  • Medical association publications
  • Government-funded or independent entities that assess and report on clinical care decisions and technology such as Agency for Healthcare Research and Quality (AHRQ), Hayes Technology Assessment, Up-To-Date, Cochrane Reviews, National Institute for Health and Care Excellence (NICE), etc.
  • Published expert opinions    
  • Opinion of Board certified health professionals in the area of specialty involved   
  • Opinion of attending provider in case at hand   
  • Only appropriate practitioners can make the decision to deny coverage of a requested service based on medical necessity guidelines

 

For Commerical

1. Health Plan Eligibility and Evidence of Coverage

(Benefit plan package)

3. UHC Health Plan Benefit Coverage, Medical Policy or Clinical Guidelines

https://www.uhcprovider.com/en/policies-protocols/commercial-policies/commercial-medical-drug-policies.html

4. National/Specialty Guidelines

If No UHC medical Guidelines, use National/Specialty Guidelines (e.g., McKesson InterQual, USPSTF, AHA/ACC, American Imaging Management, Milliman (MCG), EviCore, etc.)

MCG criteria without subscription here

5. Health Plan “APPROVED” Group Adopted Evidence Based Guidelines

6. Other Evidenced-based Criteria

7. Provider Group or IPA Criteria or Guidelines

8. Community Resources

(Peer reviewed journals or published resources)

9. Professional Physician Reviewer Judgment

If none apply, professional Physician reviewer judgment is used.