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A Prior Authorization team member can walk you through the process.

Prior Authorization

The Prior Authorization Department streamlines the process of referring your patients to specialists by:

  • Making sure the service needed is in-network and the requested procedure or treatment is necessary
  • Making the referral and prior authorization process as easy as possible for your office
  • Eliminating many of the phone calls your practice receives for these services
  • Processing approvals in a timely manner

Care coordination services are available for ALL patients covered under your PHPprime contracts.

Care Coordination

The Care Coordination Department works together with physicians, patients and family members to:

  • Support efficient transitions between care settings and home
  • Coach patients and family members in health education and self-management skills
  • Help connect patients with appropriate resources for advance directives, long-term care planning, behavioral health issues, caregiver support, and psychosocial needs

Contact the PHP Contracting team for answers and assistance accessing the data and resources you need.

Contracting and MCS Login Support

The Contracting Department manages details regarding service or participation agreements related to contracts your practice participates in as part of PHPprime, including:

  • IPA provider participation agreements
  • Health plan contracts with PHPprime, reimbursement, and product participation
  • Data Access and Usage Agreements related to sharing of protected health information (PHI)
  • Credentialing of new providers or termination of existing providers (physician/midlevel)
  • Preferred specialty provider lists and requests for consideration to be added
  • Online MCS prior authorization portal login and setup support

The Provider Relations team is here to help coordinate resources and facilitate resolutions.

Provider Relations

Provider Relations is the go-to source for our provider practices, connecting you with the PHP resources you need and disseminating and explaining pertinent information with regard to:

  • Patient eligibility issues
  • Practice resources
  • New programs or contracts
  • PHPprime information
  • User training for online MCS prior authorization portal
  • Provider portal access
  • PHP activities or events for your practice
  • General questions

Contact your PHP quality improvement coach for guidance.

Clinical Quality Improvement

The Quality Improvement Department helps practices build sustainable processes to deliver comprehensive, patient-centered care through data and continuous quality improvement initiatives. Quality improvement coaches provide guidance with:

  • Meeting clinical quality measure goals for all PHPprime health plan contracts
  • STARS measures (Medicare Advantage) and PHPprime bonus criteria measures
  • Facilitating NCQA recognition programs for diabetes, heart/stroke, and patient-centered medical home
  • Optimizing EHR and Meaningful Use reports
  • Assessing and implementing processes to increase access to quality patient care
  • Achieving Part IV Maintenance of Certification for family medicine practices

Connect with a PHP coding educator for help with Medicare Advantage documentation and coding.

Risk Adjustment Coding

The Coding Education team helps each practice maximize accuracy of patient care documentation and Risk Adjustment Factor (RAF) scores by:

  • Striving to learn about each provider’s documentation and coding habits to help identify needs
  • Conducting regular chart review and giving each provider an in-depth analysis on missed opportunities and areas for improvement
  • Keeping each practice up to date with the most current documentation and coding guidelines