MCG Clinical Criteria
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 time for complete files.
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 ratings 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.
- Criteria
- MCG · Medicare NCD/LCD
- 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.
· To be treated with respect and recognition of your dignity and privacy
· To receive complete information about your diagnosis, treatment, and alternatives in terms you understand
· To actively participate in decisions about your care, including the right to refuse treatment
· To 24-hour access to your primary care physician (PCP) or covering physician
· To a timely, organized system for grievances and appeals
The clinical criteria used to make medical necessity determinations — with the evidence considered and the rationale — are publicly posted at no cost and without login in our clinical criteria library. A copy of the specific criteria used in any determination is provided with the determination and available on request at support@procaremso.com or (657) 206-8700.
Full details on Member Resources →
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
· Provider disputes within 120 days → Providerdisputes@procaremso.com
· SNP MOC, Cultural Linguistics, FWA, HIPAA & Compliance training
The clinical criteria used to make medical necessity determinations — with the evidence considered and the rationale — are publicly posted at no cost and without login in our clinical criteria library. MCG clinical criteria apply where Traditional Medicare coverage is not fully established; NCD, LCD, and the Medicare Internet-Only Manuals govern where it is. A copy of the specific criteria used in any determination is provided with the determination and available on request at support@procaremso.com or (657) 206-8700.
Full details on Provider Resources →
Forms
Required training
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
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 ratings while protecting margin.
Specialized post-acute programs
For shared-risk contracts and bundled arrangements.