Tools and support for healthcare providers
Please login through our QuickCap ProCare Web Portal:
Compatibility: Google Chrome
For Provider Portal login requests, please email support@procaremso.com
Mailing Address:
{IPA NAME}c/o ProcareMSO
P.O Box 7820
La verne, CA 91750
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:
{IPA Name}℅ ProcareMSO PDR
PO BOX 25629
Santa Ana, CA 92799
Or email to: Providerdisputes@procaremso.com
Second-Level Review: If not satisfied with the initial provider dispute resolution, you may submit a second-level review request, within 180 days, directly to the Member's Health Plan.
For 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. Clinicians and members have the right to request a copy of a guideline that ProCare has used to make a treatment authorization decision.
*Medical Necessity includes all healthcare services necessary for the diagnosis and/or treatment of a medical condition causing significant pain, negative impact on the health status of the member, potential disability or that is potentially life threatening.
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. A copy of the Medical Criteria guidelines can be delivered upon request by emailing support@procaremso.com or by telephone at 657-206-8700.
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 Authorization Determination or a Peer to Peer discussion, call our Utilization Management Nurse at 657-206-8700.
IPA affiliated with ProcareMSO make medical necessity decisions (listed in order of significance) for outpatient and inpatient on a case-by-case basis, based on the hierarchical information provided on the member's health status. For Milliman Care Guidelines, you can utilize the link here: Milliman Care Guidelines. You can call 657-206-8700 to request Medical criteria of the authorization decision.
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 the treatment of the condition has been deemed to be medically necessary by Procare.
An enrollee may self-refer to OBGYN and does not need prior authorization.