Milliman Care 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.
ProCare 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, ProCare MSO 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. ProCare 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.
Customized to your IPA, Medical Group, or ACO — within regulatory requirements. Verified ops, real account leads, predictable turnaround.
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
- Milliman Care
- Prior auth
- Portal · fax · phone
- No PA for
- PCP & Ob-Gyn
Chronic Care Management
Comprehensive care coordination for patients with chronic conditions, ensuring continuity of care and improved health outcomes.
Annual Wellness Checks
Preventive care programs including annual wellness visits and health screenings to maintain optimal health.
Health Risk Assessments
Comprehensive HRAs to identify potential health issues and develop personalized care plans.
Care Coordination
Seamless coordination between healthcare providers to ensure comprehensive and efficient patient care.
Member resources, in plain English.
Find your provider, understand your benefits, and reach a real person on the Member Services line. Decision-making criteria available on request.
· Be treated with respect and recognition of your dignity and privacy
· Receive complete information about your diagnosis and proposed treatment
· 24-hour access to your primary care physician (PCP) or covering physician
· Actively participate in decisions regarding your healthcare
· Be informed of non-emergent costs before incurring the expense
· A timely, organized system for grievances and appeals
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
· Claims fax (855) 405-2288 · Prior auth fax (888) 972-1931
· Milliman Care Guidelines for medical necessity decisions
· No PA required for assigned PCP or Ob-Gyn provider
· SNP MOC, Cultural Linguistics, FWA, HIPAA & Compliance training
· Provider disputes filed within 120 calendar days of remittance
Forms
Required training
Policies & guidelines
Health plans we work with.
Active relationships across MAPD, Medi-Medi, and commercial lines. IPAs administered by ProCare MSO operate under all four EDI codes.
SCAN Health Plan
Central Health
Molina Healthcare
UnitedHealthcare
Alignment Health
Clever Care
Premier Patient Care IPA
EDI · PPCIP
Physician Partners IPA
EDI · PPIPA
Premiercare Health IPA
EDI · PHNPA
Northern California Physician Group
EDI · NCPG1
Why groups stay with us.
We support California's care networks with personalized economics, predictable operations, and quality programs that move the metrics your contracts measure.
Personalized financial models
Built around the specific economics of your medical group or IPA — not a template.
3–5 day credentialing
A predictable bar — measured per file, reported every month.
Live Member & Provider support
Real people for clinical questions, claims, member needs, and urgent matters 24/7.
Quality care, lower cost
Programs that move Stars and HEDIS while protecting margin and RAF-HCC accuracy.