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 in the State of Maryland. 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 the updated MedStar Family Choice Maryland HealthChoice Provider Manual, which becomes effective September 7, 2020.

NOTE: The currently effective MedStar Family Choice Maryland HealthChoice Provider Manual (revised August 2018) is still available here.

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

I. Introduction

  1. Medicaid and the HealthChoice Program
  2. Introduction to 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 with MedStar Family Choice
  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 Medical Transportation (NEMT) Assistance
  3. State Support Services
  4. Scheduling Initial Appointments
  5. Early Periodic Screening Diagnosis and Treatment (EPSDT) Requirements
  6. Special Populations
  7. Rare and Expensive Case Management Program 

III. HealthChoice Benefits and Services

  1. MCO Benefits and Services Overview
  2. Optional Services Covered by MedStar Family Choice
  3. Additional Services Covered by the State (Not by MedStar Family Choice)
  4. Non-Covered Services and Benefit Limitations by the State

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 and Coordination of Benefits
  7. Medical Necessity Criteria
  8. Clinical Guidelines
  9. Timeliness of Decisions and Notifications to Providers and Members
  10. Out-of-Network Providers
  11. Referral Process
  12. Overview of Member Complaint, Grievance and Appeal Processes
  13. State HealthChoice Help Lines 

V. Pharmacy Management

  1. Pharmacy Benefit Management
  2. Mail Order Prescriptions
  3. Specialty Pharmacy Services
  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 Prescribing Guidance and Policies

VI. Claims Submission, Provider Appeals, Quality Initiatives, Provider Performance Data 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 (IRO)
  5. Quality Initiatives
  6. Provider Performance Data
  7. Pay for Performance

VII. Provider Services and Responsibilities

  1. Overview of MedStar Family Choice Provider Services
  2. Provider Services and Provider Web Portal
  3. Provider Inquiries
  4. Recredentialing
  5. Overview of Provider Responsibilities
  6. Primary Care Providers (PCP)
  7. Specialty Providers
  8. Out-of-Network Providers and Single Case Agreements
  9. Second Opinions
  10. Provider Requested Member Transfer
  11. Medical Records Requirements
  12. Confidentiality and Accuracy of Member Records
  13. Reporting Communicable Disease
  14. Advanced Directives
  15. Health Insurance Portability and Accountability Act of 1997 (HIPAA)
  16. Cultural Competency
  17. Health Literacy - Limited English Proficiency (LEP) or Reading Skills
  18. Access for Individuals with Disabilities

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: 08/06/20