Prospective Payment System (PPS) Implementation
| Date: | March 20, 2024 |
| From: | Health Plan |
| To: | All Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Providers, Facilities, and Hospitals |
| Type: | Regulatory |
| Subject: | Prospective Payment System (PPS) Implementation |
| Business: | Medi-Cal Managed Care |
Health Plan is introducing Optum’s Prospective Payment System (PPS) which has two components: EASYGroup and Rate Manager. As a result, providers may see a change in pricing due to the pricing methodology from Optum. The system will go live March 25, 2024. For more information on EASYGroup and Rate Manager, please see below.
EASYGroup is the claims application that integrates with Health Plan’s adjudication system that contains the editors, groupers, mappers, and pricing logic.
Rate Manager handles provider contracts and rate files that contain the provider specific grouping and pricing variables required by EASYGroup. Users capture, store, and maintain all the provider-specific and payer-specific rate data, weights, means, and trims from which individual provider contracts are priced.
Rate Manager combines all of the Optum-configured rate files (both National Medicare Provider Rate Files (NMPRF) and State Medicaid Rate Files) into one functional set of contracts that feeds EASYGroup and Payment System Interface (PSI).
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG