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 90,000 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.

Click here to download a PDF version of the current MedStar Family Choice Provider Manual (revised August 2018).
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NOTE: The previous provider manual is a available for download here.

Each section of the current manual can be accessed by clicking the hyperlinks below.

I. Introduction

  1. Medicaid and the HealthChoice Program
  2. Overview of MedStar Family Choice
  3. Member Rights and Responsibilities
  4. HIPAA and Member Privacy Rights
  5. Anti-Gag Provisions
  6. Assignment and Reassignment of Members
  7. Credentialing and Contracting
  8. Provider Reimbursement
  9. Self-Referral and Emergency Services
  10. Maryland Continuity of Care Provisions

II. Outreach and Support Services, Appointment Scheduling, EPSDT, and Special Populations

  1. MCO Outreach and Support Services
  2. State Non-Emergency Transportation Services
  3. State Support Services
  4. Scheduling Appointments
  5. Early Periodic Screening Diagnosis and Treatment (EPSDT)
  6. Special Needs Populations
  7. Rare and Expensive Case Management Program 

III. Member Benefits and Services

  1. MCO Benefits and Services Overview
  2. Optional Services Covered by MedStar Family Choice
  3. Additional Services Covered by the State
  4. Non-Covered Services and Benefit Limitations

IV. Prior Authorization and Member Complaint, Grievance, and Appeal Procedures

  1. Services Requiring Prior Authorization
  2. Services not Requiring Preauthorization
  3. Prior Authorization Procedures
  4. Inpatient Admissions and Concurrent Review
  5. Period of Preauthorization
  6. Prior Authorization/Coordination of Benefits
  7. Medical Necessity Criteria
  8. Clinical Guidelines
  9. Timeliness of Decisions
  10. Out-of-Network Providers
  11. Referral Process
  12. Complaint, Grievance, and Appeal Procedures
  13. State HealthChoice Help Lines 

V. Pharmacy Management

  1. Pharmacy Benefit Management
  2. Mail Order Pharmacy (if applicable)
  3. Specialty Pharmacy
  4. Prescriptions and Drug Formulary
  5. Prescription Copays
  6. Over-the-Counter Products
  7. Injectables and Non-Formulary Medications Requiring Prior-Authorization
  8. Prior Authorization Process
  9. Step Therapy and Quantity Limits
  10. Maryland Prescription Drug Monitoring Program
  11. Corrective Managed Care Program
  12. Maryland Opioid Policy

VI. Claims Submission, Provider Appeals, MCO Quality Initiatives, and Pay-for-Performance

  1. Facts to Know Before You Bill
  2. Submitting Claims to MedStar Family Choice
  3. Provider Appeal of MedStar Family Choice Claim Denial
  4. State’s Independent Review Organization
  5. MCO Quality Initiatives
  6. Provider Performance Data
  7. Pay for Performance

VII. Provider Services and Responsibilities

  1. Overview of Provider Services Department
  2. Provider Web Portal
  3. Provider Inquiries
  4. Recredentialing
  5. Overview of Provider Responsibilities
  6. Self-Referred and Emergency Services
  7. Primary Care Providers
  8. Specialty Providers
  9. Out-of-Network Providers and Single Case Agreements
  10. Second Opinions
  11. Nurse Advice Line
  12. Provider Requested Member Transfer
  13. Medical Records Requirements
  14. Confidentiality and Accuracy of Member Records
  15. Reporting Communicable Disease
  16. Advanced Directives
  17. Health Insurance Portability and Accountability Act of 1997 (HIPAA)
  18. Cultural Competency
  19. Health Literacy
  20. Access for Individuals with Disabilities
  21. Roles and Responsibilities of MedStar Family Choice Providers

VIII. Quality Assurance Monitoring Plan and Reporting Fraud, Waste, and Abuse

ATTACHMENT A-Rare and Expensive Case Management Program
ATTACHMENT B-School Based Health Center Health Visit Report
ATTACHMENT C-Local Health ACCU and NEMT Transportation Contact List
ATTACHMENT D-Local Health Service Request Form
ATTACHMENT E-Maryland Prenatal Risk Assessment Form

Information current as of: 08/30/19