Provider Information

Authorization and Eligibility

Quality Management Program & Policies

Quality Management Program, Policies and Procedures are available upon request to members and providers by calling our Customer Service department at (657) 206-8700 Opt. 8, Monday-Friday between 9:00 AM to 5:00 PM PT.

Utilization Management Policies

Procedures and Criteria are disseminated to members and providers upon request by calling our Customer Service department at (657) 206-8700 Opt. 8, Monday-Friday between 9:00 AM to 5:00 PM PT. 

For questions or concern about the Authorization determination, the requesting practitioner may call our UM Department to discuss a denial, deferral, modification, or termination decision with the physician (or peer) reviewer at  (657) 206-8700, Monday-Friday between 9:00 AM to 5:00 PM PT. All calls will be returned within 24 hours.

Provider Authorization Manual

Read 

No prior authorization is required for:

  • Assigned PCP; or

  • Ob-Gyn Provider

All initial and follow up requests for specialty consults require a prior authorization from:

  • Assigned PCP; or

  • Contracted SCP

Urgent Referrals (PCP and SCP)

Urgent referrals are only to be submitted if the normal time frame for authorization will:

  • Be detrimental to the patient's life or health; or

  • Jeopardize patient's ability to regain maximum function; or

  • Result in loss of life, limb or other major bodily function

All referrals not meeting urgent criteria will be downgraded to a routine referral request and follow routine turn-around times.

Provider Authorization Portal

 

Provider Portal Guidelines

Read

All procedure requests including Initial and follow up requests for Specialty services require prior authorization(s):

Use the Treatment Authorization Request Form

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. 

Impartiality Statement

All participating practitioners are ensured independence and impartiality in making referral decisions which will not influence hiring, compensation, termination, promotion or any other similar matters.

Prior Authorization for treatment requests can be done by:

  • Electronically through the Provider Portal
  • Fax the Prior Authorization Treatment Request (link to the P.A form here) to 855-405-2288
  • Verbal requests by calling 657-206-8700

Questions or concerns about Authorization Determination or a Peer to Peer discussion, call our Utilization Management Nurse at 657-206-8700.

Standing Referral Policy

A request for a standing referral to a specialist may be initiated by the member, the primary care physician (PCP), or the specialty care physician (SCP), when the member has a disabling, life threatening or degenerative condition, including human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) or any condition or disease that requires specialized medical care over a prolonged period of time.

Standing referrals will be made to those specialty providers that have demonstrated expertise in treating the condition and the treatment of the condition has been deemed to be medically necessary by Procare.

An enrollee may self-refer to OBGYN and does not need prior authorization.

Non-contracted Medicare Provider Dispute Resolution (PDR) Process

A payment dispute may be filed when the provider contends that the amount paid by the payer for a covered service is less than the amount that would have been paid under Original Medicare.  To dispute a claim payment, submit a written request within 120 calendar days of the remittance notification date and include at a minimum:

A statement indicating factual or legal basis for the dispute

copy of the original claim
A copy of the remittance notice showing the claim payment
Any additional information, clinical records, or documentation to support the dispute

Mail the payment dispute (PDR)  to:

Premier Patient Care IPA
℅ ProcareMSO PDR 
P.O Box 7820
La Verne, CA 91750

If not satisfied with the initial provider dispute resolution, you may submit a second level review request, within 180 days, directly to the Member’s Health Plan. 

Appeals Process for Non-contracted Medicare Providers

For payment denial determination, in whole or in part, including issues related to bundling, level of care, or down coding of services/DRG.  You can submit the appeal directly with the Member's Health Plan. If a revision is material, we will try to provide at least 30 days’ notice prior to any new terms taking effect. What constitutes a material change will be determined at our sole discretion.

Claims Submissins

Effective January 1st, 2024, Premier Patient Care IPA PAYER ID for EDI 837 electronic claims submission for both Professional and Institutional claims will be changed from PCMSO to PPCIP under Office Ally Clearinghouse (or any clearing house you are with).

All other options to submit claims to Premier Patient Care IPA will  remain the same as follow:

Paper claims send to: 

Premier Patient Care IPA
c/o ProcareMSO
P.O Box 7820
La verne, CA 91750

Procare Provider Portal

By Fax:

855-405-2288 or 888-972-1931

For Claims status or questions email us at claims@procaremso.com. For urgent claims questions, call 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.