Massachusetts Partnership for
Correctional Healthcare

Provider Manual

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May 2015

Provider Manual

Table of Contents
MPCH Overview ............................................................................................................................................ 5
MPCH Guiding Principles .............................................................................................................................. 5
MPCH Approach ............................................................................................................................................ 5
MPCH Summary ............................................................................................................................................ 6
Working with MPCH...................................................................................................................................... 6
MPCH Regional Office Key Utilization Management Staff ........................................................................ 6
MADOC Facility Names and Contact Numbers ......................................................................................... 7
MPCH On-Site Services ................................................................................................................................. 7
On-Site Practitioners ................................................................................................................................. 8
On-Site Practitioner Availability ................................................................................................................ 8
24-Hour Access ......................................................................................................................................... 8
Monitoring Healthcare Services.................................................................................................................... 9
Specialty Care, Emergency Department and Hospitalization Accessibility/Coordination ............................ 9
Specialty Care Prior Authorization ................................................................................................................ 9
Emergency Department Services ................................................................................................................ 10
Hospitalization ............................................................................................................................................ 10
Specialty Provider Responsibilities ............................................................................................................. 10
Working with the Inmates .......................................................................................................................... 11
Continuity of Care ....................................................................................................................................... 11
Specialist Appointment Access Standards .................................................................................................. 12
Hospital Responsibilities ............................................................................................................................. 12
Provider Assistance with Public Health Services ........................................................................................ 12

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Credentialing Requirements ....................................................................................................................... 13
Recredentialing ........................................................................................................................................... 13
Provider/Facility Site Review ...................................................................................................................... 13
Eligibility ...................................................................................................................................................... 13
Billing and Claims ........................................................................................................................................ 14
General Billing Guidelines ....................................................................................................................... 14
Billing the Inmate .................................................................................................................................... 15
Clean Claim Definition............................................................................................................................. 15
Non-Clean Claim Definition..................................................................................................................... 15
Timely Filing ............................................................................................................................................ 15
Electronic Claims Submission.................................................................................................................. 16
Paper Claims Submission ........................................................................................................................ 16
Unsatisfactory or Claim Payment Concerns............................................................................................ 17
Provider Relations Assistance ..................................................................................................................... 17
Provider Updates .................................................................................................................................... 17
Provider Complaints................................................................................................................................ 17
MPCH Pharmacy Program........................................................................................................................... 18
Pharmacy and Therapeutics (P&T) Committee ...................................................................................... 18
Medical Records.......................................................................................................................................... 18
Overview ................................................................................................................................................. 18
Release of Medical Records .................................................................................................................... 19
Medical Records Audits .......................................................................................................................... 19
MPCH Medical Management Department ................................................................................................. 19
Overview and Medical Necessity ............................................................................................................ 19

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Prior Authorization Overview ................................................................................................................. 20
On-Site Practitioner Referral for Specialty Service ................................................................................. 21
Specialist Referral to Specialist for Treatment or Second Opinion......................................................... 21
Process to Request Follow-Up Specialty Services ................................................................................... 21
Self-Directed Care ................................................................................................................................... 21
Medical Necessity ................................................................................................................................... 22
Review Criteria ........................................................................................................................................ 22
Requirements for Providers to Notify MPCH Medical Management Department..................................... 23
Emergency Services ................................................................................................................................ 23
Notification of Observation Stays ........................................................................................................... 23
Concurrent Review.................................................................................................................................. 24
Discharge Planning .................................................................................................................................. 24
Retrospective Review.............................................................................................................................. 25
Summary ..................................................................................................................................................... 25

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MPCH Overview
Welcome to the Massachusetts Partnership for Correctional Healthcare (MPCH) Provider
Manual.
MPCH is a company established by two of the oldest and most respected names in correctional
healthcare and managed Medicaid services: MHM Services, Inc. and Centene Corporation. This
innovative partnership brings a combination of recruiting, program management and proven
care principles to both the on-site and off-site correctional healthcare operations.
MPCH has entered into an agreement with the Massachusetts Department of Correction
(MADOC) to provide comprehensive healthcare services to inmates throughout the
Commonwealth’s correctional system. MPCH is committed to building collaborative
partnerships with Providers.
MPCH serves the MADOC consistent with our core philosophy that quality correctional
healthcare requires coordination of care provided within the correctional facility and the services
provided “outside the walls.” Headquartered in the greater Boston area, all MPCH employees
that work within MADOC and Providers are based in Massachusetts.

MPCH Guiding Principles
In your dealings with MPCH you will find that we apply the following guidelines to all our
interactions. We…
•
•
•
•
•
•
•

Provide access to high quality, accessible, cost-effective healthcare
Perform our functions with integrity, operating at the highest ethical standards
Build mutual respect and trust in our working relationships
Create communication that is open, consistent and two-way
Embrace diversity of people, cultures, and ideas
Encourage innovation to challenge the status quo
Stress teamwork and meeting our commitments to one another

Also, please note that MPCH welcomes open Provider communication regarding appropriate
treatment alternatives. MPCH does not penalize Providers for discussing medically necessary,
appropriate care or treatment options with our on-site primary care physicians.

MPCH Approach
Recognizing that a strong healthcare program is predicated on building mutually satisfactory
associations with Providers, MPCH is committed to:
•
•

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Working as partners with participating Providers
Performing our administrative and clinical responsibilities in a superior fashion

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As much as possible, MPCH programs, policies and procedures are designed to minimize the
administrative responsibilities in the management of care, enabling the Provider to focus on the
healthcare needs of their patients.

MPCH Summary
MPCH’s philosophy is to provide access to high quality healthcare services by combining the
expertise of on-site primary care practitioners and specialty providers/specialty services with a
highly successful, experienced managed care administrator. MPCH believes that successful
patient outcomes are the result of providing care that is medically necessary, rendered in the
appropriate setting and at the appropriate interval.
It is the policy of MPCH to conduct its business affairs in accordance with the standards and
rules of ethical business conduct and to abide by all applicable federal and Massachusetts
laws.
MPCH takes the privacy and confidentiality of health information seriously. We have
processes, policies and procedures to comply with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and Massachusetts Privacy Law requirements.

Working with MPCH
For your convenience, we have included a quick reference guide to provide an overview of your
role in providing care and recommendations for care as part of your MPCH contract. The
information below and throughout this manual will include information that should assist you and
your day-to-day operations staff. The information includes:
•
•
•
•
•
•

Contact information for MPCH Medical Management Department (Utilization
Management staff)
Name and contact number for Department of Corrections sites
Claims submission and contact information
Role of the MPCH on-site practitioner
The referral process and your role
Information required by MPCH on-site healthcare team for continuity and provision of
care

MPCH Regional Office Key Utilization Management Staff
MPCH Medical Management Department
(Utilization Management Staff)
MPCH Statewide Medical Director
MPCH Chief Nursing Officer

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1-855-330-2330
1-855-330-2330
1-855-330-2330

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MADOC Facility Names and Contact Numbers
Bay State Correctional Center
Boston Pre Release Center
Bridgewater State Hospital
Massachusetts Alcohol and Substance Abuse Center
Massachusetts Treatment Center
MCI-Cedar Junction
MCI-Concord
MCI-Framingham
MCI-Norfolk
MCI Plymouth
MCI Shirley
North Central Correctional Institution (Gardner)
Northeastern Correctional Institution
Old Colony Correctional Center
Pondville Correctional Center
South Middlesex Correctional Center
Souza-Baranowski Correctional Center

508-668-1687
617-822-5000
508-279-4500
508-279-3500
508-279-8100
508-660-8059
978-405-6100
508-532-5100
508-660-5900
508-291-2441
978-425-4341
978-630-6000
978-405-6100
508-279-6000
508-660-3924
508-872-0281
978-514-6500

MPCH On-Site Services
Most on-site Healthcare Services Units operate 24 hours a day, 7 days a week. The type of
staff used to provide services besides practitioner staff include registered nurses, licensed
practical nurses, certified nurse assistants, medical assistants, medical records clerks, and
secretarial/administrative assistant staff.
The sites also provide on-site mental health and dental staff to allow a full complement of onsite care capabilities. Sites are managed by a clinical and administrative team that may include
a Medical Director, Director of Nursing, and/or Health services Administrator.
Medication services include provision of all practitioner ordered medications. These are
managed on-site and generally provided by single dose administration. There are medical
infirmaries which are staffed with nursing staff 24 hours a day, 7 days a week to allow provision
of higher level of medical care such as IV management, wound care, and pre/post op care.
The goal of health services within a correctional services contract is to perform as much
care/service on-site to minimize the need to transport inmates outside of the facility. We strive
to provide appropriate level of care and services while minimizing the risk to public safety by
transporting inmates to outside service providers.
Healthcare services that are routinely provided by on-site services and/or mobile service
providers include:

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•

•

•

CLIA waivered tests such as blood glucose monitoring, urine pregnancy tests, blood
guaiac tests, etc. Sites also draw all routine labs. These labs are drawn, prepared,
picked-up, and results completed/returned by a contracted lab vendor.
Radiology services include routine chest, and extremity radiographs. Some sites may
also have availability of services provided by a mobile vendor for ultrasound, MRI,
mammography, etc.
Dialysis services

On-Site Practitioners
Practitioners providing care can include a combination of physicians, nurse practitioners
and physician assistants. On-site practitioners are MPCH employee and serve as the
primary care provider and ‘medical home for the management of inmate patient care.
Site practitioners are responsible for providing/performing care and management of urgent and
routine medical care. They are also responsible for care and management of inmate patients
with chronic disease. Site practitioners are also responsible for requesting and managing
inmate patient specialty care. Inmate patients are not allowed to ‘self-refer’ for a specialty
provider/service as allowed in the community.
The on-site practitioners submit requests for specialty service based on the MPCH prior
authorization list (PAL) for services identified as requiring medical necessity determination.
MPCH uses InterQual and other evidence-based criteria to assess medical necessity of the
request. Our program uses a two level review system where trained utilization management
nurses perform Level 1 review. Any request not meeting criteria for Level 1 approval is deferred
to our MPCH Statewide Regional Medical Director for final determination

On-Site Practitioner Availability
Availability is defined as the extent to which MPCH employs the appropriate type and number of
practitioners necessary to meet the needs of the inmate patient population housed in the
institution. As part of our contract with MADOC, MPCH provides all the on-site practitioner staff.
Most on-site practitioner staff are provided Monday through Friday during the day; however,
larger sites with more complex inmate patients may include evening and/or weekend coverage.
Hours of practitioner time on-site can range from 4 hours/week for a very small site to 80
hours+/week for larger sites.

24-Hour Access
Regardless of the assigned staffing at the site, MPCH provides access to on-call practitioner(s)
24 hours a day, 7 days a week. Access to a provider can include a practitioner returning to the
facility for such things as suturing.

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Monitoring Healthcare Services
MPCH monitors the quality of our healthcare services in numerous ways to include the
following:

Department

Network &
Contract
Management

Medical
Management/
UM

Data Available

Frequency
of
Monitoring

On-site
Practitioner
Availability

Ensures that MPCH employs the
appropriate type and number of on-site
practitioners and specialty care
providers/services necessary for
Specialty
appropriate and timely access to care.
Provider and
Analyzes a variety of reports to determine
Specialty Service
if additional Providers may be required
Availability
Prior Auth &
Ensures prior authorization and
Concurrent
management of care based on evidence
Review
based practice guidelines

On-site Quality
Improvement
Complaints
Monitoring
Quality
Improvement
Committee
(QIC)

Description

Monitors provision of on-site and off-site
access to care; tracks and trends inmate
complaints and grievances.

Ongoing

Daily
Ongoing
Analyzed
Quarterly

Summary information is reported for review
Audits
Meetings at
and recommendation at the QIC and is
Process and
least
incorporated into MPCH’s annual
Outcome Studies assessment of quality improvement
Quarterly
activities

Specialty Care, Emergency Department and Hospitalization
Accessibility/Coordination
As part of our health services contract, MPCH has a Medical Management Department. The
department includes utilization management staff performing prior authorization, concurrent
review, retrospective reviews, appeals management, and other utilization review activities.

Specialty Care Prior Authorization
On-site practitioners are responsible for requesting any services requiring prior authorization.
Therefore, prior to the inmate being scheduled an appointment, the service requested, such as
‘initial evaluation and treatment recommendations’ will have been authorized. Upon return from
a specialist visit, the on-site practitioner will review the evaluation and recommendations from
the specialist. Based on the recommendations, the on-site practitioner may submit a new

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request for additional services that were recommended as part of the initial specialty
consultation. You, as the specialist, are not responsible for requesting the prior authorization.

Emergency Department Services
Emergency department visits do not require prior authorization. If an inmate patient is sent to
your emergency department for services, the on-site nursing staff will notify you that the inmate
is in route to your facility and provide report regarding the patient’s current care/status. Inmates
presenting to the emergency room will be transported by one or two correctional officers who
will stay with the inmate throughout the course of the emergency department visit.
Our on-site nursing supervisor will routinely make contact with the emergency department
requesting updates for prolonged visits. If it is determined the inmate will require hospitalization,
it is important to contact the referring site’s healthcare nursing supervisor. If the inmate requires
transfer to another institution, you will need to work in conjunction with the correctional officers
and site healthcare staff regarding the transfer. Inmates requiring transfer to an inpatient bed or
inpatient facility will be followed by MPCH utilization management staff.

Hospitalization
Pre-planned hospitalizations require prior authorization. The prior authorization process is
initially managed by the on-site practitioner. Upon admission to the hospital, MPCH utilization
management staff should be notified. While the on-site nursing staff provide notification to the
MPCH utilization management staff, we also request that the utilization review staff at the
inpatient facility provide notification regarding the inmate patient admission to the facility.
Management of concurrent review of hospitalized inmate patients is coordinated by the MPCH
utilization management staff. Our staff coordinate review with hospital utilization staff and
provide necessary updates for the on-site practitioner and nursing staff. MPCH utilization
management staff also assist with coordinating discussions related to discharge planning. The
goal of discharge planning is to discharge the inmate back to the facility as soon as medically
indicated; remembering that discharge planning may include release back to one of the
correctional facilities that have infirmary capabilities.

Specialty Provider Responsibilities
Specialty services are obtained within the MPCH network upon approval of the prior
authorization request initiated by the on-site practitioner. Specialists may complete diagnostic
tests if part of the authorized service. It is important to remember that when coordinating
scheduling, the on-site staff should be informed of results of testing and patient history that may
be required as part of the specialty visit. These documents, test results, radiology exams, etc.
will be sent with the inmate for your review.

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If an immediate need arises during the visit to your office and you feel additional services,
evaluation, testing may be required immediately; you will be required to contact the MPCH
Medical Management Department to request prior authorization for those services. This would
include such requests as, referral to another specialist or admission to the hospital. Prior
authorization is not required in a true emergency situation. However, all non-emergency
inpatient admissions require prior authorization from MPCH.
Please call the Utilization Management team at 1-855-330-2330 for prior authorization
before performing any tests or procedures that are not part of the original authorization
for this visit.

Working with the Inmates
The inmate patient will be accompanied by one or two correctional officers whenever he/she
comes for an appointment. The officers transporting will work closely with you and your office
staff to provide privacy for your other patients. MPCH and MADOC will work with you to
minimize any disruption to your other patients.
The transporting correctional officer staff will provide you and your staff with a sealed envelope
that include the inmate patient’s confidential medical record. The packet may also include a
document on which you can briefly document the synopsis of the encounter/visit. If a document
is not included, simply document the note on a standard progress note from your office and
include a copy with the returning records. All medical record information should be placed back
in the envelope, re-sealed and provided to the transporting correctional officers prior to leaving
your office.
When working with the inmate patient, it is important that you do not share any information with
him/her specific to follow-up recommendations and particularly follow-up appointment dates, if
already and/or previously scheduled. If at any point you realize that you have informed the
inmate patient of an upcoming appointment date and/or time, it is important that you notify the
healthcare unit immediately to permit the appointment to be rescheduled.

Continuity of Care
Since MPCH on-site practitioners are responsible for continuity of care, it is extremely important
that they obtain timely and thorough documentation from you, as the specialist, related to your
evaluation and treatment recommendations for the inmate patient. Therefore, important
responsibilities of you as the specialist include:
•
•
•

Coordinate the inmate patient’s care with the on-site practitioner
Complete written evaluation/report and return as part of the inmate patient’s visit
Provide the on-site practitioner with complete consult report and other appropriate
records within 5 business days of seeing the inmate patient

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Specialist Appointment Access Standards
Timely access to appointments for inmate patients requiring evaluation and/or follow-up care is
important to providing acceptable access to services as well as to maintaining positive
outcomes. MPCH staff responsible for coordinating scheduling will work with your office
scheduler or designee to identify routine process for scheduling, including routine times/days of
the weeks that may be coordinated or set aside for easier access to appointments.
Our contracts routinely require that specialty appointments be completed within a designated
timeframe from the time of their prior approval by our utilization management staff. Our
Utilization Management staff will work closely to work with you to access services within our
specified time frames.
MPCH will monitor appointment timeliness and access to specialty services as part of our
ongoing Quality Improvement Program. Issues specific to access and timeliness will be
discussed with individual providers and/or services if required.

Hospital Responsibilities
MPCH utilizes a network of hospitals to provide services to inmates. Hospitals providing
services as part of the MCPH network will work with Utilization Management staff for the
following:
•
•
•

•
•
•

Obtain authorization for inpatient services and non-emergent outpatient services except
for emergency stabilization services
Notify MPCH Medical Management Department of all maternity admissions upon
admission and all other admissions by close of the following business day
Notify MPCH Medical Management Department of all newborn deliveries on the same
day as the delivery, and notify MassHealth of the birth (when applicable). Note: MPCH
is not responsible for the payment of newborn services
Perform concurrent review and discharge planning in conjunction with MPCH utilization
management staff
Assist in determining most appropriate and lowest level of care to provide medically
necessary care
Assist in providing continuity of care from hospital facility back to the correctional
institution.

MPCH network hospitals should refer to their contract for complete information regarding the
hospitals’ obligations and reimbursement.

Provider Assistance with Public Health Services
MPCH is required to coordinate with public health entities regarding the provision of public
health services. Providers must assist MPCH in these efforts by working with the MPCH
Chief Nursing Officer or designee in:

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•

•
•

•

Complying with public health reporting requirements regarding communicable
diseases and/or diseases which are preventable by immunization as defined by
Massachusetts law
Assisting in the notification or referral of any communicable disease outbreaks involving
inmate patients to the local public health entity as defined by Massachusetts law
Assisting in the notification or referral to the local public health entity for tuberculosis
contact investigation, evaluation, and the preventive treatment of persons with whom
the inmate patient has come into contact.
Assisting in referring inmate patients to the local public health entity for STD/HIV contact
investigation, evaluation, and preventive treatment of persons whom the inmate patient
has come into contact.

Credentialing Requirements
Physicians and applicable ancillary providers must complete the credentialing process to be a
participating provider with MPCH. MPCH recognizes the credentialing information supplied by
CAQH if the provider is already registered. A single-page demographic form is the only
requirement for CAQH participating providers.
Credentialing materials can be found in the Provider section of the Centurion website at:

www.centurionmanagedcare.com

Recredentialing
Specialty providers must comply with the recredentialing policy of one JCH accredited facility at
a minimum.

Provider/Facility Site Review
Site visits are performed on a case-by-case basis in cooperation with the provider, provider
practice or inpatient facility. Site visits will be performed by MPCH Medical Management
Department staff. Site visits will be coordinated, as indicated, with the provider office
management staff and/or inpatient utilization management staff prior to the visit. MPCH Medical
Management Department staff will work with designated provider/facility staff to define
reason/purpose of the visit to allow for proper coordination and provision of information required,
if indicated.

Eligibility
Eligibility has a slightly different meaning in a correctional system. Eligibility is tied directly to
the inmate being housed and/or ‘on count’ at a MADOC facility. Therefore, inmates are
considered ‘eligible’ for authorized services from the date of incarceration to the date of release

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from the MADOC. It is important to understand that there may be times when inmates are
released from facilities and then, may be re-arrested and returned to the MADOC system. If this
occurs, the inmate is not eligible for MPCH payment of services during the time they are
released from the facility until re-arrested.
It is important to ensure that your staff managing scheduling understand that an inmate will
never contact them directly to schedule an appointment. Appointment scheduling will always be
completed for services being authorized/paid for by MPCH through a MPCH healthcare staff
member. Inmates will be escorted by MADOC correctional officers for all appointments. If a
person presents without a MADOC escort, the Provider must call the MPCH Medical
Management Department to determine whether the person is still incarcerated.
MPCH is not financially responsible for services the person receives prior to or upon discharge
from the MADOC. If you have questions, it is best to contact Medical Management regarding
the inmate’s eligibility for services. MPCH is not responsible for the services provided to a
newborn of a MDOC inmate.

Billing and Claims
General Billing Guidelines
MPCH processes claims in accordance with applicable State prompt pay requirements.
Physicians, other licensed health professionals, facilities, and ancillary Provider’s contract
directly with MPCH for payment of covered services.
It is important that Providers ensure MPCH has accurate billing information on file. Please
confirm with your Provider Relations Department that the following information is current in
our files:
•
•
•
•
•
•

Practitioner or Provider Name (as noted on current W-9 form)
National Provider Identifier (NPI)
Tax Identification Number (TIN)
Taxonomy Code
Physical location address (as noted on current W-9 form)
Billing name and address (if different)

Providers must bill with their NPI number in box 24Jb on the CMS1500 (HCFA) or box 56 on the
CMS1450 (UB04). We encourage Providers to also bill their taxonomy code in box 24Ja to
avoid possible delays in processing. Claims missing the requirements will be returned and a
notice sent to the Provider, creating payment delays. Such claims are not considered “clean,”
and therefore cannot be accepted into our system.
We recommend that Providers notify MPCH in advance, but no later than 30 days, of changes
pertaining to billing information. Please submit this information on a W-9 form. Changes to a
Provider’s Tax Identification Number (TIN) and/or address cannot be processed when

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conveyed via a claim form. Such changes must be communicated as noted in the Provider
Update section of this manual.
Claims eligible for payment must meet the following requirements:
•
The inmate was incarcerated on the date of service
•
Referral and Prior Authorization processes were followed, if applicable
Paper claims must be submitted on standard CMS1500 (HCFA) and CMS1450 (UB04) red
claim forms. Photo copies and faxes of claim forms will not be accepted for processing and will
be returned and a notice sent to the Provider requesting resubmission. Black and white claim
forms are only accepted when submitting information for a claim dispute.
Payment for service is contingent upon compliance with referral and prior authorization policies
and procedures, as well as the billing guidelines outlined in this manual and the Provider Billing
Guide

Billing the Inmate
Inmates cannot be billed directly for any service or co-pay.

Clean Claim Definition
A clean claim is defined as a claim received by MPCH for adjudication, in a nationally
accepted format in compliance with standard coding guidelines and which requires no further
information, adjustment, or alteration by the provider of services in order to be processed by
MPCH. The following exceptions apply to this definition: (a) a claim for which fraud is
suspected; and (b) a claim for which a Third Party Resource should be responsible.

Non-Clean Claim Definition
A non-clean claim is defined as a submitted claim that requires further investigation or
development beyond the information contained in the claim. The errors or omissions in the
claim may result in: (a) a request for additional information from the Provider or other external
sources to resolve or correct data omitted from the claim; (b) the need for review of additional
medical records; or (c) the need for other information necessary to resolve discrepancies. In
addition, non-clean claims may involve issues regarding Medical Necessity and include claims
not submitted with the filing deadlines.

Timely Filing
Contracted Providers (in Network) must submit all original claims (first time claims) and
encounters within 120 calendar days from the date of service.
Non-Contracted Providers (out of Network) must submit all original claims (first time
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claims) and encounters within 120 calendar days from the date of service.
The filing limit may be extended where the eligibility has been retroactively received by
MPCH, up to a maximum of 365 calendar days.
All corrected claims, requests for reconsideration, or claim disputes must be
received within 120 calendar days from the date of notification of payment or
denial is issued.

Electronic Claims Submission
Emdeon Payer ID -

42140

Network Providers are encouraged to participate in MPCH’s Electronic Claims/Encounter Filing
Program. MPCH has the capability to receive an ANSI X12N 837 professional, institution, or
encounter transaction. In addition, it has the ability to generate an ANSI X12N 835 electronic
remittance advice known as an Explanation of Payment (EOP). For more information on
electronic filing please call (800) 225-2573 Ext. 25525 or 314-505-6525.
Providers that bill electronically are responsible for filing claims within the same filing deadlines
as Providers filing paper claims. Providers that bill electronically must monitor their error reports
and evidence of payments to ensure all submitted claims and encounters appear on the reports.
Providers are responsible for correcting any errors and resubmitting the affiliated claims.

Paper Claims Submission
All paper claims and encounters should be submitted as follows:
Mailing address for Paper Claims:
MPCH
PO Box 4090
Farmington, MO 63640-4198
Timely Filing
Claims should be submitted within 120 days from date of service for consideration. Providers
should expect payment within 30 days after receipt of a clean claim.

General Claim Inquiries
Please call 1-855-330-2330

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Unsatisfactory or Claim Payment Concerns
If a Provider has a question or is not satisfied with the information they have received
related to a claim, there are effective ways in which a Provider can contact MPCH
program:
1.
2.
3.
4.

Submit a Corrected Claim
Submit a “Request for Reconsideration”
Contact a MPCH Provider Relations Representative at 1-855-330-2330
Submit a Claim Dispute.

All disputed claims will be processed in compliance with the claims payment resolution
procedure as described in the Provider Complaints section of this manual.

Provider Relations Assistance
Providers may seek assistance through our regional office staff at 1-855-330-2330

Provider Updates
To ensure that we can communicate with you effectively, and to avoid any possible delay in
claim payment, it is important that you notify us, in writing, as soon as you are aware of any of
the following situations:
Addition or termination of an office location.
Addition, change, or termination of Tax Identification Number (W-9 required).
Name change (W-9 may be required).
Change in ownership.
Change in a phone number, fax, or e-mail address.
Change in office hours, panel capacity, or age limitation

Provider Complaints
Providers have the right to initiate a formal complaint regarding dissatisfaction with MPCH
administrative policy or process. Please contact our regional office at 1-855-330-2330 and ask
to speak with the Executive Director who can help you process your concern.
Complaints about adverse decisions for medical services and or procedures will be reviewed by
the MPCH Statewide Medical Director or the appropriate qualified medical professional(s).
Provider complaints related to a medical management decision, including expressing
dissatisfaction with a decision, will be handled at time of receipt. Please call the statewide
medical director at 1-855-330-2330 to discuss your concern.

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MPCH Pharmacy Program
MPCH covers all prescription drugs for MADOC inmates that are ordered as part of their on-site
treatment plan. MPCH utilizes a formulary for provision of MADOC healthcare services.
Providers are encouraged to use the approved formulary. Please contact the MPCH Regional
Office for a copy of the current formulary. When making recommendations for medications as
part of the inmate patient’s treatment plan, we ask that providers be knowledgeable and
understanding that medications that can be easily abused or offer ‘benefits’ from the inmate
standpoint, i.e., abusable narcotics, (inmate can get a ‘high’ from them) can only be
recommended when the provider feels that the medication is the most medically appropriate. If
medications are recommended in your treatment plan that are not on the current
MPCH/MADOC formulary, the on-site practitioner will review the request and obtaining the
recommended medication will require the on-site practitioner to obtain non-formulary approval.
So, again, it is important to familiarize yourself and any other treating staff with the formulary.
Our on-site healthcare staff are responsible for ordering, managing and administering all
medications ordered for inmates in the institution. We obtain medications for all MADOC
correctional facilities through an arrangement with the State Office of Pharmacy Services
(SOPS).

Pharmacy and Therapeutics (P&T) Committee
The MPCH P&T Committee continually evaluates the therapeutic classes included on the
formulary. The committee is composed of the MPCH Statewide Medical Director, Pharmacy
Program Director, MADOC Clinical D\director and MPCH site Medical Director(s) and other
appropriate medical professionals. The primary purpose of the committee is to assist in
developing and monitoring the MPCH formulary and to establish programs and procedures that
promote the appropriate and cost-effective use of medications. The P&T Committee schedules
meetings at least quarterly.

Medical Records
Overview
MPCH Providers must keep accurate and complete medical records that comply with all
statutory and regulatory requirements. MPCH primary care providers maintain medical
records for all inmates. Timely and complete provision of care information specific to inmate
patient services allows MPCH on-site medical practitioners to make informed care decisions
and maintain continuity of care. Also, maintenance of records by you as the Provider will
enable provision of quality healthcare service to MADOC inmate patients. Specialty providers
are expected to provide copies of records of services provided by the specialist for inclusion in
the inmate comprehensive medical record maintained at the prison site.
MPCH uses Provider medical record information as an avenue to review the quality and
appropriateness of the services rendered. Provision of privacy and confidentiality of records

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for care provided to inmate patients is no different than the requirements for any patient you
provide services for in the community. Massachusetts administrative regulations require
Providers to maintain all records for at least 6 years after the date of medical services for
which claims are made, or the date services were prescribed. Specialty physician will not
provide copies of medical records to inmates. If an inmate requests a copy of his medical
record the specialists should refer the inmate to the Health Services Administrator at the
prison.

Release of Medical Records
All inmate patient medical records shall be confidential, and shall not be released without the
written authorization. All requests for medical records should be referred the health service
administrator at the prison. Inmates cannot be provided copies or originals of medical records
information by any treating Provider or Facility. MADOC policy for acquiring medical records
must be followed.

Medical Records Audits
MPCH routinely audits medical records maintained at the prisons including documentation
provided by specialist and hospitals. MPCH may contact providers if the audit results raise
questions about medical documentation provided by the specialists or hospital

MPCH Medical Management Department
Overview and Medical Necessity
The MPCH Medical Management Department hours of operation are Monday through Friday
(excluding holidays) from 8:00 a.m. to 5:00 p.m. Authorization may be requested via telephone
or fax.
For telephone authorizations during business hours, the Provider should contact:
Prior Authorization – 1-855-330-2330
Inpatient Concurrent Review – 1-855-330-2330
The MPCH Utilization Management (UM) Program is designed to ensure inmates receive
access to the right care, at the right place, and at the right time. Our program is comprehensive
in scope to ensure services provided are medically necessary, appropriate to the inmate’s
condition, rendered in the most appropriate setting, timely, and meet nationally recognized
standards of care.
MPCH’s UM Program includes:

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•
•
•
•
•
•

Prior Authorization
Concurrent Review
Retrospective Review
Discharge Coordination
Complex Case Management
Assistance with Complex Medical Release Cases

Our medical management program goals include:
•
•
•
•
•
•

•
•
•

Healthcare based on evidence-based guidelines/practice
Monitoring utilization patterns to guard against over or under utilization
Development and distribution of clinical practice guidelines to Providers to promote
improved clinical outcomes and satisfaction
Identification and provision of intensive care and/or disease management for inmates at
risk, or with complex care needs
Education of Providers to promote improved clinical outcomes
Coordination of care with sites to ensure implementation of programs that encourage
preventive services and proactive management of chronic condition and focus on selfmanagement
Focus on early identification and management of inmates with complex care needs
Creation of partnerships with Providers to enhance cooperation and support for
UM program goals.
Coordinated discharge planning program to ensure appropriate utilization of on-site
infirmary and specialized care units in order to minimize hospital length of stays

Prior Authorization Overview
For MPCH, the prior authorization process is driven by the on-site Medical Director or
practitioner at the individual correctional facility. The on-site practitioners will initiate all requests
for provision of specialty services to include any additional follow-up care or treatment
recommended based on a specialty provider evaluation or follow-up visit. The on-site
practitioner may request additional clinical input from the specialty Provider to document
medical need for requested service(s).
MPCH considers prior authorization as a request to MPCH’s Utilization Management
Department for determination of medical necessity for elective services on the Prior
Authorization List. This process requires completion and approval prior to the service being
scheduled/delivered.
Therefore, an inmate should never automatically be scheduled by the specialty provider for a
follow-up visit. Follow-up appointments and requests for additional services are managed by
the on-site Medical Director and practitioners.
MPCH requires Prior Authorization for certain inpatient and outpatient services and treatments,
as well as treatment at MPCH Designated Tertiary Facilities or when treated by Providers
practicing in affiliation with those facilities.

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Always contact the MPCH Medical Management Department if there is any doubt about whether
or not a service requires Prior Authorization or has been already been pre-authorized.

On-Site Practitioner Referral for Specialty Service
MPCH’s expectation is that on-site practitioners coordinate all ongoing healthcare services.
MPCH requires a referral and prior authorization for all specialty services prior to the service
being scheduled and/or provided if the service is routine or urgent in nature. Prior Authorization
number will be provided by the MPCH clinical scheduling staff at the time of appointment
scheduling if prior authorization is required in order to provide coverage for referrals to all
specialists
MPCH requires that all specialty Providers submit feedback to the referring on-site MCPH
practitioner, in writing, that provides the practitioner the outcome of the examination, tests
performed or recommended, and/or any treatment recommendations. Written report should
include any discussion, education provided directly to the inmate patient regarding
recommendations

Specialist Referral to Specialist for Treatment or Second Opinion
When medically necessary services are beyond the scope of the Specialist’s practice, or,
when a second opinion is requested, the Specialist must collaborate with the MPCH on-site
practitioner. The MPCH practitioner will be responsible for requesting authorization for the
service.

Process to Request Follow-Up Specialty Services
Specialist should contact the MPCH referring on-site practitioner for discussion regarding
additional service recommendations requested during an active appointment. Failure to contact
the referring practitioner and/or MPCH utilization management staff for prior authorization of
additional services may result in non-payment of those services

Self-Directed Care
Inmates are not allowed to self-direct care. All services provided must be approved by
MPCH. If your office is contacted directly by an inmate, please contact Medical
Management Department immediately to request clarification of the patient’s eligibility.
Inmates upon release, are allowed to use any community provider; however, once released
from the facility, MPCH will no longer be responsible for cost of services.

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Prior Authorization Response Timeline
Routine Prior Authorization Requests:
•
Decisions shall be made within two business days of receipt of all information
necessary to make a decision
•
The requesting practitioner will be called within 24 hours of the decision
•
Written notice of an approval is sent to the practitioner and site Healthcare
Services Unit within two business days of the verbal notification
Expedited Prior Authorization Requests:
•
Decisions will be made as soon as possible taking into account medical urgency
and always within two business days
•
The requesting practitioner will be called within one business day of the decision
•
Written notice of an approval is sent to the practitioner and site Healthcare
Services Unit within two business days of the verbal notification
•
Notification of an adverse determination is sent to the practitioner and site
Healthcare Unit within 24 hours after the decision and no later than 72 hours after
the receipt of the request
•
The decision timeframe may be extended if necessary, once, up to 48 hours if
MPCH utilization management staff are unable to render a determination
based on lack of information required to complete the review.

Medical Necessity
MPCH defines Medical Necessity as healthcare services that are consistent with generally
accepted principles of professional medical practice as determined by whether:
a) The service or level of service is the most appropriate available considering potential
benefits and harms to the inmate patient
b) Service is known to be effective, based on scientific evidence, professional
standards and expert opinion in improving health outcomes
c) For services and interventions not in widespread use, services are based on
scientific evidence and are the least intensive and most cost-effective available.

Review Criteria
MPCH has adopted the utilization review criteria developed by McKesson InterQual Products
Specialists representing a national panel from community-based and academic practice, to
determine Medical Necessity for non-emergency inpatient and outpatient services.
InterQual criteria are applied to:
•
Medical and surgical admissions
•
Select outpatient procedures
•
Ancillary services
Criteria are established, periodically evaluated and updated with appropriate involvement from

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physicians of Centurion’s Medical Management Services and the Centurion Quality
Improvement Committee. InterQual is utilized as a screening guide and is not intended to be a
substitute for practitioner judgment. Utilization review decisions are made in accordance with
currently accepted medical or healthcare practices, taking into account special circumstances of
each case that may require deviation from the norm in the screening criteria. Criteria are used
for the approval of Medical Necessity, but not for the denial of services. The MPCH Statewide
Medical Director or designee is the only individual authorized to make adverse determinations.
Providers may request an appeal related to a Medical Necessity decision made during the
authorization or concurrent review process. The appeal may be submitted at 1-855-330-2330

Requirements for Providers to Notify MPCH Medical
Management Department
Emergency Services
Prior authorization is not required; however, MPCH Medical Management Department should be
notified within one business day of admission to the Emergency Department and/or subsequent
hospitalization secondary to the Emergency Department visit. Notification should include
clinical information related to the emergency services and/or need for hospital admission.

Notification of Observation Stays
It is the responsibility of the receiving hospital and/or Emergency Department to notify MPCH
Medical Management Department of all Observation Stays
Definition of Observation Stay
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If an inmate patient’s clinical symptoms do not meet criteria for an inpatient
admission, but the treating Physician believes that allowing the inmate patient to
leave the facility would likely put the inmate patient at serious risk, he/she may be
admitted to the facility for an Observation Stay. Such stays should be reviewed with
the MPCH on-site or on-call practitioner or MPCH Medical Management Department
(Monday through Friday during business hours) to obtain authorization for inpatient
stay and initiate discharge planning discussions to ensure inmate patient care cannot
be managed by an on-site MADOC infirmary
Observation Services are those services furnished on a hospital’s premises,
including use of a bed and periodic monitoring by a hospital’s nurse or other staff
These services are reasonable and necessary to:
o
Evaluate an acutely ill condition
o
Determine the need for a possible inpatient hospital admission
o
Provide aggressive treatment for an acute condition.
Observation stays may last a maximum of 48 hours
If an inmate patient begins treatment in observation status and then transitions to an
inpatient stay, all incurred observation charges and services will be rolled into the
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acute inpatient reimbursement rate, or as designated by the contractual
arrangement with MPCH. Observation is not separately reimbursed when the stay
results in an inpatient admission.

Concurrent Review
MPCH utilization management (UM) staff perform ongoing concurrent review for all inpatient
admissions. MPCH UM staff will review the treatment and status of all inmate patients receiving
inpatient services through contact with the hospital’s Care Management Department and the
attending Physician, when necessary. On-site and telephonic models are utilized to conduct
utilization review in collaboration with the hospital Care Management Department.
An inpatient stay will be reviewed as indicated by the diagnosis and response to treatment. The
review will include evaluation of the current status, proposed plan of care, discharge plan, and
any subsequent diagnostic testing or procedures.
Inpatient concurrent review authorization decisions are made within one calendar day of
receipt of all necessary information and Providers are verbally informed of the decision within
one calendar day of the decision. Written or electronic notification includes the number of
days of service approved, and the next review date.
In the case of a denial of service days:
•
•
•
•

Written notices are sent within one business day of the verbal notification
All existing approved services will be continued without liability to the until the Provider
has been notified of an adverse determination
MPCH UM staff will work directly with the hospital’s Care Management Department to
facilitate discharge back to an appropriate MADOC level of care facility
Notices will contain information on how to appeal

Discharge Planning
Discharge planning activities are expected to be initiated upon admission. The MPCH UM staff
will coordinate the discharge planning efforts with the hospital’s Care Management Department,
and when necessary, the attending Physician in order to ensure that inmate patient receives
appropriate post-hospital discharge care. It should be noted that MADOC infirmaries can
provide a skilled level of services to inmate patients supporting earlier discharges from the
hospital.
Hospital Care Management Departments are encouraged to develop understanding of level of
care and services that can be provided by MPCH/MADOC on-site infirmaries. This level of
understanding will assist in promoting coordination of discharge planning with MPCH UM staff.

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Retrospective Review
Retrospective review occurs when an initial review of the services provided to an inmate patient
occurs after the date of service. This is sometimes necessary because authorization and/or
timely notification were not obtained prior to the service delivery due to extenuating
circumstances.
Routinely this process encompasses services performed by a Provider when there was no
opportunity for concurrent review. However, retrospective review is also performed on active
cases where an appropriate authorization decision cannot be made concurrently within the
required timeframe due to lack of clinical information. For cases that qualify for a retrospective
review, a decision is made within 30 calendar days of receipt of all necessary information.

Summary
The information presented in this Provider Manual is meant to present to Specialty providers
and their staff an overview of coordinating services with MPCH. Specific questions should be
directed to MPCH Medical Management Department staff.

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