Obtaining Decision-Making Criteria
The clinical criteria used for medical necessity decisions are publicly posted, at no cost and without login, in our clinical criteria library. No account or sign-in is required to read them.
Clinical Criteria Used for Medical Necessity Decisions
ProCare MSO administers utilization management for its affiliated IPAs, including Premier Patient Care IPA (PPCIPA). The clinical criteria used to make medical necessity determinations, the summary of evidence considered, and the rationale for adoption are publicly available at no cost and without login at https://mso.procareprovider.com/clinical-criteria
Where Traditional Medicare coverage criteria are fully established, determinations follow the applicable National Coverage Determination (NCD), the Local Coverage Determination (LCD) for the service area, and the Medicare Internet-Only Manuals, each linked on that page. Where Traditional Medicare coverage criteria are not fully established, PPCIPA applies publicly posted internal coverage criteria based on current, widely used treatment guidelines and clinical literature, as described on that page.
A copy of the specific criteria used in a determination is also provided with each authorization determination and is available on request at support@procaremso.com or 657-206-8700.
Criteria library — open each set directly
- CMS National Coverage Determinations (NCD)
- CMS Local Coverage Determinations (LCD)
- MCG 30th Edition — Inpatient Guidelines
- MCG 30th Edition — Outpatient Guidelines
To discuss a denial, request an appeal, or obtain a copy of the criteria used to make a determination, please call our Member Services Department at (657) 206-8700.
Affirmative Statement
- Utilization decisions are based only on appropriateness of care and service.
- No person involved in the authorization process may receive compensation for denial of care.
- No person involved in the authorization process may receive an incentive, whether financial or non-financial, directly or indirectly, to encourage denials.
- The utilization management process includes systems to monitor for over/under-utilization of services — analysis and monitoring reports, identification of issues, development of a clinical care management plan, and evaluation of the actions.
Member Rights & Responsibilities
As a member/patient of ProCare, you have many key rights, but also some important responsibilities. ProCare is committed to seeing to it that your rights are respected at all times — by upholding your responsibilities, you can ensure a satisfying member experience.
Your Rights Include:
- To exercise these rights without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment
- To be treated with respect, and with recognition of your dignity and privacy
- To be provided with information about your IPA, its services, and the healthcare service delivery process
- To be informed of the name, qualifications, and titles of the physician that has primary responsibility for coordinating your care, and of the names, qualifications, and specialties of other professionals who may be involved in your care
- To have 24-hour access to your primary care physician (PCP) or covering physician
- To receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, as well as prospects for recovery, in terms that are understandable to you
- To be informed of continuing healthcare requirements following office visits, treatments, procedures, and hospitalizations
- To actively participate in decisions regarding your healthcare and treatment plan — including, to the extent permitted by law, the right to refuse any procedure or treatment (if refused, an explanation will be given by your provider addressing the effect(s) on your health)
- To have access to personal medical records based upon state and federal requirements
- To be informed of non-emergent costs of care and receive an explanation of your financial obligations prior to incurring the expense (including co-payments, deductibles, and co-insurance)
- To examine and receive an explanation of bills generated for services delivered to you
- To be informed of applicable rules in the various healthcare settings regarding member conduct
- To express opinions or concerns regarding your IPA or the care provided; to offer recommendations for change; and to have a timely and organized system for resolving member complaints and formal grievances
- To be informed of the member grievance and appeals process
- To change your PCP by contacting your health plan
- To receive reasonable continuity of care and be given timely and sensible responses to questions and requests made for service
- To be able to formulate advance directives for healthcare
These member rights shall apply to any person that has legal responsibility to make healthcare decisions for you. Members also have the right to be represented by parents, guardians, family members, or other conservators if they are unable to fully participate in their own treatment decisions.
Physician Profiles
Our partnered physicians share our vision of providing high-quality care to our members. To find out if your physician belongs to ProCare's network, please call (657) 206-8700.
If your physician is not in our network but is interested in joining, please have them call us and we will be more than happy to assist in enrollment.
Advance Directives
Advance directives refer to a personalized healthcare treatment plan that allows your physician, family, and friends to know your care preferences in times when you may not be able to express them yourself. These important wishes include special treatment that you may or may not want at the end of your life, as well as your desire for diagnostic testing, surgical procedures, cardiopulmonary resuscitation, and organ donation.
Although these may not be easy decisions to make, by considering your options now you can ensure the quality of life that is important to you and avoid the grief, stress, and arguments that may arise when leaving your loved ones to guess at your wishes when critical medical decisions need to be made.