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Provider Manual

HealthChoice is Maryland's Medicaid managed care program. Overseen by the Maryland Department of Health (MDH), the HealthChoice program serves over 500,000 individuals. These individuals are enrolled in one of the participating managed care organizations (MCOs). Currently, MedStar Family Choice has approximately 42,000 members. Each MCO has policies and procedures that providers who deliver services to recipients must adhere to. Any questions a provider has about the policies of individual MCOs should be addressed by the provider information supplied by the MCO they participate in.

While each HealthChoice MCO has its own policies and procedures, many program elements apply to all providers, regardless of the MCO. The purpose of the manual is to explain those elements and be a useful reference for providers who participate in the HealthChoice program.

The MedStar Family Choice Provider Manual advises you about the MedStar Family Choice Managed Care Organization, including its policies and procedures relative to providing care. It also contains useful contact information to assist our network providers and their staffs.

If you would like, you may download a PDF version of the entire manual. Otherwise, the provider manual can be viewed by specific chapters and sections.

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I. General Information Maryland HealthChoice Program

  • The Maryland HealthChoice Program
  • MedStar Family Choice
  • Rights and Responsibilities
  • Anti-Gag Provisions
  • Assignment and Reassignment of a Member
  • Becoming a Provider
  • Provider information Changes
  • Provider Performance Data
  • Provider Terminations
  • HealthChoice Eligibility
  • Provider Reimbursement
  • Medical Record Documentation
  • Self Referral and Emergency Services
  • Self-Referred Services for Children with Special Healthcare Needs
  • PCP Contract Terminations
  • Continuity of Care
  • Specialty Referrals
  • Transportation
  • School Based Health Center Visit Report Form

II. Provider Responsibilities

  • Role and Responsibilities of Primary Care Provider
  • Role and Responsibilities of Specialist Provider
  • Role and Responsibilities of OB/GYN Provider
  • Reporting Communicable Disease
  • Appointment Scheduling and Outreach Requirements
  • Services for Children
  • Special Needs Populations
    • Services Every Special Needs Population Receives
    • Special Populations-Outreach and Referral to LHD
    • Services for Pregnant and Post Partum Women
    • Children with Special Health Care Needs
    • Individuals with HIV/AIDS
    • Individuals with Physical or Developmental Disabilities
    • Individuals Who are Homeless
    • Adult Members with Impaired Cognitive Ability/Psychosocial Problems
  • MedStar Family Choice Care Management
  • Outreach
    • Initial Health Assessments
    • Non-Compliant Members
    • Transportation Guidelines
  • Case Management and Disease Management
    • Complex Case Management
    • Disease Management
  • Health Education
  • Interpreter Services
  • Eligibility Verification
  • Referrals
    • Routine Referrals
    • Laboratory Referrals
    • Nurse Advice Line
    • OB/GYN Referrals
    • Radiology Referrals
    • Rehabilitation Referrals
    • Self-Referrals for Dental and Vision
    • Urgent/Emergent Referrals
  • Utilization Management
    • Pharmacy
    • Initial Request for Inpatient Authorization
    • Concurrent Review
    • Emergency Care
    • Services Requiring Prior-Authorization
    • Services not requiring authorization if completed by Network providers at network facilities
    • Injectables and Non-Formulary Medication Requiring Prior-Authorization
    • New Technology
  • HIPAA
  • Claims
    • Submitting Claims
    • Claims Appeal Process
    • ER Auto-Pay List
    • Overpayments-Refunds

III. HealthChoice Benefits and Services

  • Overview
  • Covered Benefits and Services
    • Audiology for Adults
    • Blood and Blood Products
    • Case Management Services
    • Dental Services for Children and Pregnant Women
    • Diabetes Care Services
    • Dialysis Services
    • Disease Management
    • Durable Medical Equipment and Supplies
    • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services
    • Family Planning Services
    • Home Health Services
    • Hospice Care Services
    • Inpatient Hospital Services
    • Laboratory Services
    • Long-term Care Facility Services/Nursing Facility Services
    • Outpatient Hospital Services
    • Oxygen and Related Respiratory Equipment
    • Pharmacy Services
    • Physician and Advanced Practice Nurse Specialty Care Services
    • Podiatry Services
    • Primary Care Services
    • Primary Behavioral Health Services
    • Rehabilitative Services
    • Second Opinions
    • Transplants
    • Vision Care Services
    • Additional Benefits Covered by MedStar Family Choice
    • Benefit Limitations
  • Medicaid Covered Services that are not the Responsibility of MedStar Family Choice
  • Self-Referral Services

IV. Rare and Expensive Case Management (REM) Program

  • Overview
  • Medicaid Services and Benefits
  • Case Management Services
  • Care Coordination
  • Referral and Enrollment Process
  • Rare and Expensive Disease List

V. DHMH Quality Improvement and MCO Oversight Activities

  • Quality Assurance Monitoring Plan
    • Fraud and Abuse
    • Quarterly Complaint Reporting
  •  MedStar Family Choice Member Hotline
  •  MedStar Family Choice Member Complaint/Grievance Policy and Procedure
    • Member Internal Grievance/Complaint Procedure
    • Second Level Grievance Review Procedure (Grievance Appeal)
    • Medical Coverage Appeals Process for Members
    • Urgent Appeals
    • Non-Urgent Appeals
  • MedStar Family Choice Provider Grievance/Appeal Process
    • Clinical Dispute Reviews and Administrative Dispute Reviews
    • First Level Provider Disputes
    • Second Level Provider Disputes
  • Independent Review Organization 
  • DHMH Quality Oversight: Complaint and Appeal Processes
    • HealthChoice Help Line
    • Provider Hotline
    • Complaint Resolution Division
    • Ombudsman Program
    • Departmental Dispute Resolution
    • Member Appeal
Information current as of: 07/18/17