Quality, Clinical Practice Guidelines, and Medical Necessity

We strive to meet the highest quality and safety standards.

ProCare Advantage (HMO-POS I-SNP) is designed to meet the needs of our members in collaboration with health care partners. We strive to meet the highest quality and safety standards while ensuring efficient and cost-effective care is delivered.

We follow CMS requirements, health plan standards developed by URAC, and HEDIS measure standards developed by the National Committee for Quality Assurance (NCQA) as a guide to support optimal care for members.

Collaboration with providers is key to ensuring a quality health care experience for enrolled members. Quality program objectives include:

  • Improving the health status of ProCare Advantage Members.
  • Ensuring access to high quality and safe health care services in the ProCare Advantage service area.

For more information about the ProCare Advantage Quality program, please call Member Services at 1-844-206-3719 (TTY 711). Calls to this number are free.

Clinical Practice Guidelines

The following clinical practice guidelines are intended to support our health care team and serve as resources to ensure our providers have the most up to date, evidence-based information recommended by nationally recognized organizations. AMDA – The Society for Post-Acute and Long-Term Care Medicine  – This is the standard care process in the post-acute and long-term care (PA/LTC) setting.

Guidelines are provided for informational purposes only and are not meant to direct individual treatment decisions. All patient care and related decisions are the sole responsibility of providers. These guidelines do not dictate or control a provider’s clinical judgement regarding the appropriate treatment of a patient in any given case.

Medical Necessity

“Medically Necessary” or “Medical Necessity” means health care services or supplies that a physician, exercising prudent judgement, would provide and/or order for a patient. The services must be:

  1. a) in accordance with generally accepted standards of medical practice;
  2. b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
  3. c) not primarily for the convenience of the patient, physician, or other health care provider, and
  4. d) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease

ProCare Advantage utilizes the following Medical Necessity criteria to guide utilization management decisions. This may include, but is not limited to, decisions involving inpatient reviews, prior authorizations, level of care, and retrospective reviews.

  1. Centers for Medicare and Medicaid (CMS) Criteria
  2. Milliman Care Guidelines (MGC)

ProCare Advantage Medical Necessity criteria does not supersede state or Federal law or regulation.