Billing and Claims
For instructions on how to submit a claim with Maryland Physicians Care, please see our Claims Submission Guide (PDF).
Claims will be considered for reimbursement only if MPC appropriately authorizes them, are a covered benefit, and the enrollee is eligible at the time of service.
If prior authorization is required, the prior authorization number must be entered on the appropriate billing form. However, authorizations in themselves are not guarantees of payment.
Sudden and Serious
The ER Sudden and Serious List (PDF) includes the ICD-10 codes designating an emergency room visit requiring immediate medical attention. The ER Sudden and Serious List will automatically adjudicate the hospital claims.
Claims/Encounter Data Reporting Requirements
Providers shall utilize the most current diagnostic and procedure coding guidelines, including but not limited to International Classification of Diseases (ICD), American Medical Association Current Procedural Terminology (AMA CPT), Health Care Financing Administration Common Procedural Coding System (HCPCS), Diagnostic Statistical Manual (DSM), Current Dental Terminology (CDT), and Uniform Billing Data Elements (UB-04) Specification Manual.
Providers may contact MPC’s Provider Services to check the status of claims submitted for reimbursement, clarify any denials or other claim processing actions. Provider Services can be reached at 1-800-953-8854 and then follow the prompts. Registered network providers may also perform claims inquiries through the employment of MPC’s HIPAA-compliant web portal, My MPC Source.
Provider Overpayment Refunds
Federal and State regulations require providers to audit claims for overpayments routinely. Medicaid funds that were improperly paid or overpaid must be returned within 60 days of discovery. If your practice determines it has received an overpayment or improper payments, you are required to return the overpayment to MPC within 60 calendar days after the date the overpayment was identified and notify MPC in writing of the reason for the overpayment.
Overpayments should be returned along with the reason for the overpayment and a copy of the Explanation of Payment(s) to:
Maryland Physicians Care
P.O. Box 22655
New York, NY 10087-2655
Timely Filing Limitations
Providers must submit electronic or paper claims to MPC for reimbursement within one hundred eighty (180) days from the service date. For a claim on a CMS 1500 claim form, one hundred eighty (180) days are counted from the day the service was performed. For a claim on a UB 04 claim form, one hundred eighty (180) days are counted from the date of discharge for the hospital or nursing homestay. Claims that are not initially received within one hundred eighty (180) days of the service date may be denied for payment.
After MPC has adjudicated a claim, you will receive a Remittance Advice with the reimbursement, which will provide details about the submitted claim and its status.
Ambulatory Surgery Center Additional Reimbursement
Effective September 1, 2023, Maryland Physicians Care will allow additional reimbursement as a bill-above for high cost implantable billed by an Ambulatory Surgery Center. An invoice with the items must accompany the claim submission. The invoice must include the member’s name, identification number, HCPCS codes and per item price.Bill-Aboves List
Ways to Manage and Submit Claims
Electronic Clearinghouse Availity
Payor ID = 76498
Please contact your Provider Relations representative for further information on electronic claims or a list of approved EDI vendors.
Maryland Physicians Care
P.O. Box 21099
Eagan, MN 55121