Provider resources.

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For Provider Portal login requests, please email support@procaremso.com.

• Premier Patient Care IPA Professional: PPCIP
• Physician Partners IPA Professional: PPIPA
• Premiercare Health IPA: PHNPA
• Northern California Physician Group: NCPG1

[Your IPA name] c/o ProCare MSO, Inc.
P.O. BOX 25629
SANTA ANA, CA 92799

Fax Number: 855-405-2288

For claims status or questions email us at claimssupport@procaremso.com.

For urgent claims questions, call 657-206-8700.

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:

For a 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.

Welcome to the Physician Training Module. Below are our provider training modules that you can access to assist you in providing care to our members. Please click on the link for your necessary training.

ProCare utilizes clinical practice guidelines as standards of healthcare that are applicable to members and providers. Our Quality Management Committee performs regular reviews of nationally and locally developed guidelines and then gives final approval on the adoption of all considered guidelines.

All clinical practice guidelines are adopted based on scientific evidence, review of the medical literature or appropriately established authority, as cited. All recommendations are based on published consensus guidelines, and not on any particular treatment or service based solely on cost consideration.

These guidelines are suggested recommendations and to be used as a guide for the purpose of making Medical Necessity* clinical decisions. Clinicians and their patients should work together to develop individual treatment plans that are personalized to the specific needs and circumstances of each patient. The clinical criteria used for medical necessity determinations are publicly posted at no cost and without login in our clinical criteria library. The specific criteria applied in a given determination are also provided with the determination notice and are available on request at 657-206-8700 or support@procaremso.com.

Where Traditional Medicare coverage criteria are not fully established, ProCare applies MCG (formerly Milliman Care Guidelines) as licensed decision-support. The MCG guideline sets adopted for medical necessity review are posted in the clinical criteria library below; the internal criterion applied, and the primary guideline or literature that supports it, are also provided with the determination.

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.

As a utilization management organization, we ensure 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 the 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. The clinical criteria used for medical necessity determinations are publicly posted at no cost and without login in our clinical criteria library. The specific criteria applied in a given determination are also provided with the determination notice and are available on request at 657-206-8700 or support@procaremso.com.

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:

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

No prior authorization is required for:

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

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 who have demonstrated expertise in treating the condition, and where the treatment of the condition has been deemed medically necessary by ProCare.

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

Per Assembly Bill 347 and California Health & Safety Code §§ 1367.206 and 1367.241, prescribers may request a step therapy exception when the required step therapy drug is inconsistent with good professional practice. Please submit the exception request with supporting clinical justification/documentation at the time of submission. If required information is missing, we will notify the prescriber within 72 hours (or within 24 hours if urgent circumstances apply). After all required information is received, the request is approved/denied within applicable statutory timeframes; failure to timely notify may result in the request being deemed approved for the duration of the prescription (including refills). Provider appeals of denials are permitted under applicable UM processes and Health & Safety Code § 1368.