Services and Solutions

ProCare MSO is a full service solution for Independent Physician Associations (IPA), Medical Groups, and Accountable Care Organizations (ACO). At ProCare MSO, we can customize our services according to the specific needs of your organization provided they meet regulatory requirements. We look forward to collaborating with you to create a full suite of services that bring your medical organizations to the next level and continually exceed patient expectations. ProCare MSO’s core suite of services includes: ACO, Claims, Credentialing, Eligibility, Finance, Member Relations, Provider Relations, Quality Management, and Utilization Management. In addition, the following services are also provided to all ProCare MSO members: Chronic Care Management, Annual Wellness Checks, Healthcare Data Analytics, and HCC/RAF Education and Management.


ACO Services

ProCare assists with your ACO assessment and management. We handle reporting, financial analysis, and quality efficiency metrics. Additionally, we can assist with contracting, network designing, and cost-containment.


Claims

ProCare MSO takes on the responsibility to timely and properly route and adjudicate all claims within the guidelines established. We set the bar high in regards to efficacy and efficiency when processing claims. We also ensure that all partnered IPAs are in compliance with the regulatory requirements and assist with preparation for health plan audits.

We answer questions and solve problems that providers may encounter regarding claims. ProCare makes it a priority to ensure that our providers are provided with the guidance and assistance they need regarding all claims.

Our team is ready to support you with Medicare (CMS) and Commercial regulatory requirements, as well as guide you through claim timeliness to ensure claims are processed correctly.

ProCare MSO’s provider portal is able to log, adjudicate, and pay claims. The portal automates whenever possible, allowing for faster claim turnaround time. We can also receive claims electronically through our partnership with Office Ally or by using a direct 837 electronic format.

Our claims department is committed to stellar customer service and proper claims adjudication.

Submitting Claims:

To submit your claims electronically via Office Ally, please refer to the following payer code: PCMSO

To submit your claims via U.S. Mail, please mail your printed claims to:

ProCare MSO, Inc.
Claims Department

P.O. Box 7820
La Verne, CA 91750

To submit your claims via Facsimile, please refer to the following fax number:

(888) 972-1931


Credentialing

Our credentialing services ensure that our clients maintain current specifications with Health Plan credentialing standards. We keep track of provider data and files and prioritize their alignment with current criteria. Our credentialing team works fast on the turnaround time, in most cases taking 3-5 days, compared to up to 3 weeks with traditional models.


Eligibility

ProCare MSO is responsible for upholding and analyzing eligibility information for our contracted Health Plans. We work to provide a constant, up-to-date reconciliation system, while not falling short on the quality and detail of our eligibility lists, updated monthly.


Finance

ProCare provides a complete financial evaluation of the profitability of our partnered IPAs. We work to ensure compliance with state and federal regulations, while providing recommendations and advisory.


Member Relations

We are always constantly looking to expand membership development and patient retention. ProCare provides assistance to all of our members in all of our IPAs. Members are encouraged to call for any inquiries or issues. Most of our staff is bilingual in local languages and can offer a helping hand.


Provider Relations

Provider Relations is one of our highest priorities at ProCare MSO. We take pride in offering assistance to our partnered providers and are always just an e-mail or a short phone call away. Our staff tirelessly works to show that our goal is to provide a helping hand.

Our provider services include:

  • Eligibility
  • Claims
  • Compliance Issues
  • Utilization Management
  • Referral Authorizations
  • Physician Office Polices and Procedures

Quality Management

The heart of ProCare MSO works to coordinate and maintain the quality of care that our providers give to their members. Our staff strives to follow all HEDIS, DHS, STATE, and NCQA guidelines regarding the quality of service of our clients and partners.


Utilization Management

Utilization Management is performed to ensure an efficient health care delivery system. It is designed to evaluate the cost and quality of medical services provided by participating physicians, hospitals, and vendors. UM decision making is based on appropriateness of care, service and existence of coverage. The goal of Utilization Management is to assure appropriate utilization by meeting the following objectives:

  • Assure fair and consistent utilization management decision-making
  • Timely resolution of identified member issues
  • Promotion and maintenance of optimal quality of care
  • Education of medical providers and other health care professionals on the appropriate and cost-effective use of health care resources

Financial rewards or incentives must not influence any utilization decisions. No rewards or incentives are given for issuing denials of coverage or service.

The Utilization Management staff is available for any questions during business hours from 8:00AM-5:00PM PST. Contact via:
Main Business Phone: (714) 947- 8600
Toll Free Phone No: (800) 375 – 4692
For Hearing Impaired: 711 California Relay Service

UM Criteria used in decision making can be obtained by contacting the UM Department at (714) 947-8600.


HCC/RAF Education and Management

ProCare’s policies revolving around HCC and RAF aim to assist our clients and partners in achieving appropriate revenue while maintaining the highest quality of care possible. Our licensed nurses and coders can train and educate your practice to meet CMS-HCC regulations. We work with you to achieve the highest risk scores possible to justify the true conditions of your patients.

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