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    Physical Health Managed Care

    Operations Memorandums

    Managed care organizations (MCOs), providers, and stakeholders can access guidance and updates to help them improve the quality of care and ensure compliance with state regulations. 

    Jump to year: 2024  |  2023  |  2022  |  2021  |  2020  |  2019  |  2018

    2024 Ops Memos

    Number
    		Category
    		Subject
    		Posted
    		Status
    MCS-09-2024-008General OperationsPrior Authorization of Breast PumpsSeptember 17, 2024Active
    MCS-07-2024-007General OperationsUtilization Review Criteria Assessment Process - Licensed Proprietary Product Review 2024July 30, 2024Active
    MCS-O5-2024-006General OperationsGuidance for Use of Service History Data Files That Include Substance Use Disorder EncountersMay 21, 2024Active
    MCS-05-2024-005General OperationsPermitting Outreach to Members who have lost coverage up to 90 days after disenrollmentMay 2, 2024Active
    MCS-03-2024-004Technology Assessment GroupTechnology Assessment Group (TAG) Coverage DecisionsMarch 21, 2024Active
    MCS-03-2024-003General OperationsNational Correct Coding Initiative (NCCI) EditsMarch 21, 2024Active
    MCS-03-2024-002General OperationsRevised Model Member Handbook TemplateMarch 21, 2024Active
    MCS-01-2024-001
    		General Operations
    		Payment for Services Associated with Qualifying Clinical Trials
    		January 03, 2024
    		Active

    2023 Ops Memos

    Number
    		Category
    		Subject
    		Posted
    		Status
    MCS-11-2023-016
    		General Operations
    		Opioid Centers of Excellence
    		November 08, 2023
    		Active
    MCS-10-2023-015
    		Technology Assessment Group
    		Office of Medical Assistance Programs (OMAP) Coverage Decisions
    		October 18, 2023
    		Active
    MCS-10-2023-014
    		Technology Assessment Group
    		Office of Medical Assistance Programs (OMAP) Coverage Decisions
    		October 18, 2023
    		Active
    MCS-10-2023-013
    		Technology Assessment Group
    		Technology Assessment Group (TAG) Coverage Decisions
    		October 18, 2023
    		Active
    MCS-10-2023-012
    		General Operations
    		Street Medicine
    		October 05, 2023
    		Active
    MCS-09-2023-011
    		General Operations
    		Requirements for Consumer Incentive Submissions
    		September 12, 2023
    		Active
    MCS-09-2023-010
    		General Operations
    		Requirements for MY 2023/RY 2024 HEDIS®, CAHPS® and Pennsylvania Performance Measure (PAPM) Submissions
    		September 6, 2023
    		Active
    MCS-07-2023-009
    		General Operations
    		Utilization Review Criteria Assessment Process - Licensed Proprietary Product Review 2023
    		July 27, 2023
    		Active
    MCS-06-2023-008
    		General Operations
    		Prior Authorization of Opioids
    		June 29, 2023
    		Active
    MCS-05-2023-007
    		Technology Assessment Group
    		Technology Assessment Group (TAG) Coverage Decisions
    		June 21, 2023
    		Active
    MCS-05-2023-006
    		Technology Assessment Group
    		Office of Medical Assistance Programs (OMAP) Coverage Decisions
    		June 21, 2023
    		Active
    MCS-05-2023-005
    		General Operations
    		New Member Outreach
    		June 21, 2023
    		Active
    MCS-05-2023-004
    		General Operations
    		Reviewing Requests for Private Duty Nursing, Home Health, and Personal Care Services For Medical Necessity
    		May 15, 2023
    		Active
    MCS-05-2023-003
    		General Operations
    		Record Review of Managed Care Organizations' Complaint and Grievance Process and Procedure
    		May 10, 2023
    		Active
    MCS-05-2023-002
    		Technology Assessment Group
    		Technology Assessment Group (TAG) Coverage Decisions
    		May 5, 2023
    		Active
    MCS-01-2023-001
    		Technology Assessment Group
    		Technology Assessment Group (TAG) Coverage Decisions
    		January 31, 2023
    		Active

    2022 Ops Memos

    Number
    		Category
    		Subject
    		Posted
    		Status
    MCS-11-2022-011
    		General Operations
    		Transportation Requests Referrals
    		November 30, 2022
    		Active
    MCS-11-2022-010
    		General Operations
    		Opioid Centers of Excellence
    		November 21, 2022
    		Obsolete
    MCS-11-2022-009
    		General Operations
    		Requirements for Consumer Incentive Submissions
    		November 14, 2022
    		Obsolete
    MCS-11-2022-008
    		Technology Assessment Group
    		Technology Assessment Group (TAG) Coverage Decisions
    		November 03, 2022
    		Active
    MCS-09-2022-007
    		General Operations
    		Requirements for MY 2022/RY 2023 HEDIS®, CAHPS® and Pennsylvania Performance Measure (PAPM) Submissions
    		September 19, 2022
    		Active
    MCS-07-2022-006
    		General Operations
    		Utilization Review Criteria Assessment Process - Licensed Proprietary Product Review 2022
    		August 04, 2022
    		Active
    MCS-07-2022-005
    		Technology Assessment Group
    		Technology Assessment Group (TAG) Coverage Decisions
    		July 26, 2022
    		Active
    MCS-07-2022-004
    		General Operations
    		Reinstatement of Prior Authorization Requirements for Private Duty/Shift Nursing Services
    		July 26, 2022
    		Active
    MCS-07-2022-003
    		Technology Assessment Group
    		Technology Assessment Group (TAG) Coverage Decisions
    		July 13, 2022
    		Active
    MCS-02-2022-002
    		Technology Assessment Group
    		Technology Assessment Group (TAG) Coverage Decisions - TAG 08-21
    		February 14, 2022
    		Active
    MCS-02-2022-001
    		General Operations
    		Requirements for MY2021/RY2022 HEDIS, CAHPS and Pennsylvania Performance Measure (PARM) Submissions
    		February 10. 2022
    		Active

    2021 Ops Memos

    Number
    		Category
    		Subject
    		Posted
    		Status
    MCS-06-2021-007General OperationsUpdates to Prior Authorization Requirements for Certain Services During the COVID-19 Public Health EmergencyJune 15, 2021Active
    MCS-06-2021-006General OperationsTechnology Assessment Group (TAG) Coverage DecisionsJune 15, 2021Active
    MCS-06-2021-005General OperationsTechnology Assessment Group (TAG) Coverage Decisions
    		June 15, 2021Active
    MCS-02-2021-003
    		General Operations
    		Increased Timeframe For Continuation of Services
    		Feb. 22, 2021
    		Active
    MCS-01-2021-002
    		General Operations
    		Technology Assessment Group (TAG) Coverage Decisions - TAG 11-19
    		Jan. 5, 2021
    		Active
    MCS-01-2021-001
    		General Operations
    		Technology Assessment Group (TAG) Coverage Decisions - TAG 2-5-20
    		Jan. 5, 2021
    		Active

    2020 Ops Memos

    Number
    		Category
    		Subject
    		Posted
    		Status
    MCS-12-2020-018
    		General Operations
    		Utilization Review Criteria Assessment Process - Licensed Proprietary Product Review LLP 2020Dec. 30, 2020
    		Obsolete
    MCS-12-2020-017
    		General Operations
    		Technology Assessment Group (TAG) Coverage Decisions
    		Dec. 8, 2020
    		Active
    MCS-11-2020-016
    		General Operations
    		Paying Legally Responsible Family Members to Provide Personal Care Services as Caregivers
    		Nov. 24, 2020
    		Active
    MCS-09-2020-015
    		General Operations
    		Verifying Medicare noncovered Durable Medical equipment (DME)
    		Sept 29, 2020
    		Active
    MCS-06-2020-014
    		General Operations
    		No Charge to medical Assistance Beneficiaries for Personal Protective Equipment
    		June 12, 2020
    		Active
    MCS-05-2020-013
    		General Operations
    		Removal of Prior Authorization for SublocadeTM (buprenorphine extended-release) Injection
    		May 26, 2020
    		Active
    MCS-05-2020-012
    		General Operations
    		Elective Services
    		May 7, 2020
    		Active
    MCS-04-2020-011
    		General Operations
    		CR Modifier and DR Condition Code for COVID-19-Disaster/Emergency Related Claims
    		April 27, 2020
    		Active
    MCS-04-2020-010
    		General Operations
    		MA Eligibility During COVID-19 Emergency Disaster Declaration
    		April 17, 2020
    		Obsolete
    MCS-04-2020-008
    		General Operations
    		New ICD-10-CM Code for the 2019 Novel Coronavirus (COVID-19)
    		April 12, 2020
    		Active
    MCS-03-2020-005
    		General Operations
    		Requirements Related to COVID-19
    		March 25, 2020
    		Obsolete
    MCS-03-2020-004
    		General Operations
    		PROMISeTM Managed Care Payment System Table
    		March 24, 2020Active
    MCS-02-2020-002
    		General Operations
    		Contraception Dispensing
    		Feb. 21, 2020
    		Active
    MCS-01-2020-001
    		General Operations
    		Requirements for 2020 HEDIS, CAHPS and Pennsylvania Performance Measure Submissions
    		Feb. 3, 2020
    		Active

    2019 Ops Memos

    Number
    		Category
    		Subject
    		Posted
    		Status
    MCS-12-2019-013
    		General Operations
    		Utilization Review Criteria Assessment Process - Licensed Proprietary Product Review 2019
    		Dec. 31, 2019
    		Obsolete
    MCS-12-2019-012
    		General Operations
    		Complaints, Grievances and Fair Hearing Templates GG (13)(16) and
    N (1)-(7) Update
    		Dec. 16, 2019
    		Active
    MCS-08-2019-011
    		General Operations
    		Technology Assessment Group Coverage Decisions
    		Oct. 22, 2019
    		Active
    MCS-06-2019-009
    		General Operations
    		Technology Assessment Group Coverage Decisions
    		June 5, 2019
    		Active
    MCS-05-2019-008
    		General Operations
    		Retrospective Review of Hospice Services Provided by managed care network Providers
    		May 23, 2019
    		Active
    MCS-04-2019-007
    		General Operations
    		2019 HealthChoices Physical Health Agreement
    		April 12, 2019
    		Active
    MCS-04-2019-006
    		General Operations
    		Removal of Substance use Disorder (SUD) Medications from Specialty Programs and Specialty Drug Lists
    		April 10, 2019
    		Active
    MCS-03-2019-005
    		General Operations
    		Technology Assessment Group Coverage Decisions
    		April 2, 2019
    		Active
    MCS-03-2019-004
    		General Operations
    		Consumer incentive Submission Requirements - Revised
    		March 8, 2019
    		Active
    MCS-03-2019-003
    		General Operations
    		Changes to Third Party Liability Requirements Related to Prenatal Services, Effective April 1, 2019
    		Feb. 27, 2019
    		Active
    MCS-02-2019-002
    		General Operations
    		Oversight of Opioid use Disorder Centers of Excellence
    		Feb. 1, 2019
    		Active

    2018 Ops Memos

    Number
    		Category
    		Subject
    		Posted
    		Status
    MCS-12/2018-024
    		General Operations
    		HealthChoices Physical Health Managed Care Organization (PH-MCO) Responsibility to Pay for Licensed Emergency Medical Agency Services when Emergency Medical Transportation is Not Provided ("Treat-No-Transport")
    		Dec. 27, 2018
    		Active
    MCS-12/2018-023
    		General Operations
    		Increased Rates for Ambulance Services, Effective January 1, 2019
    		Dec. 21, 2018
    		Active
    MCS-12/2018-022
    		General Operations
    		PROMISeTM Managed Care Payment System Table Update
    		Dec. 14, 2018
    		Active
    MCS-12/2018-021
    		General Operations
    		To provide MCOs coverage updates on new technologies as discussed in regular Technology Assessment Group (TAG) meetings
    		Dec. 5, 2018
    		Active
    MCS-10/2018-020
    		General Operations
    		All HealthChoices Physical Health Managed Care Organizations and Providers - Statewide
    		Oct. 23, 2018
    		Active
    MCS-10/2018-019
    		General Operations
    		Policies Concerning Department of Human Services Review of Requests for Residential Placement of Children for Treatment of Physical Health Conditions
    		Oct. 16, 2018
    		Active
    MCS-10/2018-018
    		General Operations
    		Payment Responsibility if a Member has Primary Coverage (Third Party Liability)
    		Oct. 10, 2018
    		Active
    MCS-09/2018-016
    		General Operations
    		Provider Pay for Performance Program Reports
    		Sept. 26, 2018
    		Obsolete
    MCS-09/2018-015
    		General Operations
    		PROMISeTM Managed Care Payment System Table
    		Sept. 1, 2018
    		Active
    MCS-08/2018-014
    		General Operations
    		Technology Assessment Group Coverage Decisions
    		Aug. 15, 2018
    		Active
    MCS-06/2018-012
    		General Operations
    		Utilization Review Criteria Assessment Process - Licensed Proprietary Product
    		June 18, 2018
    		Obsolete
    MCS-05/2018-010
    		General Operations
    		Pennsylvania Performance Measures Timeline Reporting Requirements
    		May 25, 2018
    		Active
    MCS-05/2018-009
    		General Operations
    		Technology Assessment Group Coverage Decisions
    		May 16, 2018
    		Active
    MCS-04/2018-006
    		General Operations
    		Public Health Dental Hygiene Practitioner (PHDHP) Enrollment
    		April 9, 2018
    		Active
    MCS-03/2018-004
    		General Operations
    		Technology Assessment Group Coverage Decisions
    		March 16, 2018
    		Active
    MCS-03/2018-003
    		General Operations
    		Prior Authorization of Opioids and Medication Assisted Treatment (MAT)
    		March 15, 2018
    		Active