Bureau of Managed Care Operations

The Bureau of Managed Care Operations is responsible for the administration and oversight of mandatory managed care program known as HealthChoices that provides Medical Assistance benefits to eligible recipients in Pennsylvania.

 

Managed Care Organizations:

Division of Monitoring and Compliance:

  • Monitors the HealthChoices Mandatory Managed Care Program to ensure access and quality of care for consumers
  • Implements Department program changes and new OMAP initiatives
  • Responds to recipient and provider concerns
  • Partners with consumer advocacy groups, provider associations, and other stakeholders
  • Oversees the Department wide Enrollment Assistance Program
  • Ensures the provision of enrollment services to recipients
  • Monitors the Enrollment Assistance Program contract

Division of Quality Management and Special Needs Coordination:

  • Management and facilitation of the Quarterly Quality Review Meeting (QQRM) Process
  • Management and Oversight of the Prior Authorization Review Panel (PARP) Process
  • Clinical Oversight of MCO Quality Management and Utilization Management Programs
  • Oversight and Coordination with the MCO Special Needs Unit
  • Management and facilitation of the EPSDT Age-Out Process and Complex Care Process
  • Oversight of the MCO Complaint and Grievance Processes and Management of the MCO Fair Hearing Process
  • Management of EQR Activities, HEDIS, PA Performance Measure, CAHPS and Member Level Data and Reporting
  • Management of the Pay for Performance (P4P) Programs (MCO & Provider) and Community Based Care Management Programs

Program Initiatives, Contract Management & Communications:

  • Assists with the development of Procurements
  • Facilitates website updates and postings
  • Administrates the HealthChoices managed care organizations’ Agreements & procurement processes
  • Develops internal & external management reports
  • Develops managed care & program informational materials and acts as the primary point of contact for HealthChoices program inquiry and public communications initiatives
  • Assists the OMAP and BMCO Executive Offices with research and development of new program initiatives
  • Facilitates incoming Right to Know Law Requests for the bureau
  • Administrates and monitors OMAP’s Technical Assistance and Consultative Services Contract

Medical Assistance Transportation Program:

  • Monitors the county-based MA transportation program
  • Monitors the contractor that administers the program in Philadelphia county