Apollo & Inter-Qual Guidelines
Medical necessity decisions based only on appropriateness of care.
Five-Star Quality Focus
Programs to maximize Stars ratings and RAF-HCC scores.
3–5 Day Credentialing
Predictable turnaround for complete files, measured each month.
A full-service MSO for the people who run California's care networks.
ProCareMSO is a full-service Managed Services Organization that operates in Southern and Northern California. We understand that our Independent Physician Associations, Medical Groups, and Accountable Care Organizations pride themselves on their distinct coordinated quality of care, provider networks, and reputations.
By connecting your members to a team of highly experienced healthcare executives, ProCareMSO increases efficiency, effectiveness, and overall quality of managed healthcare — focused on Medicare Advantage Part D (MAPD) and Medicare/Medi-Cal (Medi-Medi) enrollees.
To exceed our clients' expectations by offering personalized and innovative solutions to increase their financial bottom line while providing the highest quality health care services to our members.
To be an innovative leader in healthcare management to maximize patient's health and quality of care.
Quality care, lower cost — and the five-star ratings your contracts measure.
Every utilization decision is based only on the appropriateness of care and service. ProCareMSO does not provide compensation or incentives for denying care.
We help our partners achieve five-star quality ratings and the highest RAF-HCC scores possible — programs that move Stars and HEDIS while protecting margin.
Nine core services. One operating partner.
ProCareMSO can customize services to the specific needs of your organization, provided they meet regulatory requirements.
ACO
Accountable Care Organization management and coordination services.
- Focus
- Shared savings · Quality
- Network
- Clinical integration
- Reporting
- Provider scorecards
Claims
Comprehensive claims processing and management.
- EDI
- Office Ally
- IPA codes
- PPCIP · PPIPA · PHNPA · NCPG1
- Claims fax
- (855) 405-2288
- Dispute window
- 120 calendar days
Credentialing
Provider credentialing and verification services.
- Turnaround
- 3–5 days
- Sources
- Primary-source verification
- Monitoring
- License & sanctions
Eligibility
Member eligibility verification and management.
- Lookup
- Real-time portal
- Reconciliation
- Capitation lists
- Coordination
- Health plan
Finance
Financial management and reporting services.
- Models
- Personalized
- Reporting
- RAF-HCC
- Reconciliation
- Capitation
Member Relations
Member support and relationship management.
- Hotline
- Member Services
- Support
- Grievance & appeals
- Language
- Cultural & linguistic
Provider Relations
Provider network management and support.
- Portal
- QuickCap
- Leads
- Dedicated accounts
- Onboarding
- Training & growth
Quality Management
Quality assurance and improvement programs.
- Ratings
- Five-Star focus
- Risk
- RAF-HCC reporting
- Programs
- Quality scorecards
Utilization Management
Utilization review and management services.
- Guidelines
- Apollo · Inter-Qual
- Prior auth
- Portal · fax · phone
- Reviews
- Medical necessity
Risk Adjustment (RAF)
Risk adjustment education, training, and reporting, with HCC coding guidelines and encounter support to maximize accurate reimbursement to physicians.
Quality & Care Management
Quality case management and care management coordinated across the network to improve outcomes and Star ratings.
Referrals & Authorizations
A live direct and online referral process with auto-adjudicated and expedited authorizations.
Eligibility & Claims
Accurate eligibility and capitation lists, timely claims adjudication, and prompt response to providers and members.
Member resources, in plain English.
Find your provider, understand your benefits, and reach a real person on the Member Services line. Decision-making criteria and advance directive guidance available on request.
· To exercise your rights without regard to race, ethnicity, religion, sex, age, disability, sexual orientation, or source of payment
· To be treated with respect and recognition of your dignity and privacy
· To receive complete information about your diagnosis, proposed treatment, and alternatives in terms you understand
· To 24-hour access to your primary care physician (PCP) or covering physician
· To actively participate in decisions about your care, including the right to refuse treatment
· To access your personal medical records per state and federal law
· To be informed of non-emergent costs before incurring the expense
· To a timely, organized system for grievances and appeals
· To change your PCP by contacting your health plan
· To formulate advance directives for your healthcare
Less admin. More clinical time.
Credentialing in 3–5 days, prior authorization via portal or fax, and named account leads who pick up the phone.
· QuickCap Provider Portal (Google Chrome required)
· EDI claims via Office Ally: PPCIP, PPIPA, PHNPA, NCPG1
· Paper claims: P.O. Box 25629, Santa Ana, CA 92799 · Fax (855) 405-2288
· Apollo & Inter-Qual guidelines for medical necessity decisions
· Provider disputes within 120 days → Providerdisputes@procaremso.com
· Second-level review within 180 days via the member's health plan
· SNP MOC, Cultural Linguistics, FWA, HIPAA & Compliance training
Forms
Required training
Policies & guidelines
Health plans we work with.
Active relationships across MAPD, Medi-Medi, and commercial lines. IPAs administered by ProCareMSO operate under all four EDI codes.
Premier Patient Care IPA
EDI · PPCIP
Physician Partners IPA
EDI · PPIPA
Premiercare Health IPA
EDI · PHNPA
Northern California Physician Group
EDI · NCPG1
Why choose ProCareMSO.
Personalized financial models
For medical groups.
Customizable Provider progress profiles
Built around the metrics your contracts measure.
3–5 days credentialing
Turnaround time on complete files.
24/7 Provider and Member services hotline
Real people for urgent matters around the clock.
Focus on quality care and reducing costs
Programs that move Stars and HEDIS while protecting margin.
Specialized post-acute programs
For shared-risk contracts and bundled arrangements.