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Prior Authorization

Prior authorization is one way Maryland Physicians Care monitors the medical necessity and cost effectiveness of the services our members receive. Participating and nonparticipating health professionals, hospitals and other providers are required to comply with MPC's prior authorization policies and procedures. Noncompliance may result in delay or denial of reimbursement.

NEW: The clinical criteria used for audiology coverage has been posted to the provider information page of the Maryland Department of Health website. This information is available for review here: MDH Audiology Services (PDF).

  • All elective hospital admissions require prior authorization.
  • The state mandated Turnaround Time for PA requests is 2 business days when all information is received and 14 calendar days when additional information is required.
  • To ensure a timely response to your request, submit all prior authorization requests at least 14 days in advance with all required information.
  • A prior authorization request must include the following:
    • Name, date of birth, and identification number of the member
    • Gender (for gender specific procedures only)
    • Current, applicable codes which may include: Current Procedural Terminology (CPT), Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes, National Drug Code (NDC)
    • Diagnosis code: International Classification of Diseases, ICD-10 CODES
    • Name, phone and fax number of the referring/ordering practitioner or provider
    • NPI & TIN of referring/ordering practitioner or provider
    • Name, phone and fax number of the servicing practitioner or provider (place of service or facility)
    • NPI & TIN of servicing practitioner or provider
    • Reason for the request
    • Number of units requested for each code
    • Clinical information including but not limited to: supporting objective clinical information, such as clinical notes, laboratory and imaging studies, and treatment dates, as applicable for the request.

**DME/DMS requests require a pricing list or invoice included with the clinical information

**Enteral Formula and Nutritional Supplement requests require the MDH Nutritional Supplement form with the clinical information (see FORMS)

**Remote Monitoring requests require the MDH Remote Monitoring form with the clinical information (see FORMS)

To request a peer to peer regarding a Prior Authorization denial please call 443-713-4781

Leave the following information:

  • Provider name
  • Provider phone number
  • Member name
  • Member DOB
  • Authorization #
  • Provider’s available date and time(s)
  • The caller’s contact information

The provider must request the peer to peer within 2 business days of the denial being rendered.

All services listed on this guide require Prior Authorization

Please submit all required clinical information via fax: 866-753-5659

Transplant Evaluation

  1. Letter of medical necessity AND appropriate PA form.
  2. Routine complete history and physical (including pertinent routine social history) within 6 months.
  3. Basic labs (chemistries, CBC,  and liver function tests) within 6 months, plus:
    • Liver – MELD or PELD score, hepatitis serologies, imaging and biopsy as indicated.
    • Kidney - GFR (already in routine tests) or creatinine clearance if not on dialysis.
    • Heart – echo and cardiac catheterization results.
    • Lung – PFT’s, imaging, and 6-minute walk test.
    • Pancreas – BMI, C-peptide, and history of insulin treatment.
    • Intestine/Multivisceral-no additional testing.
    • Stem cell – most recent bone marrow biopsy as indicated.

Transplant Listing and Authorization Extension

  1. Letter of medical necessity from a transplant service physician
  2. Routine complete history and physical within 6 months.
  3. Basic labs(chemistries, CBC, and liver function tests) within 6 months, plus:
    • Liver – same as above.
    • Kidney – same as above plus PRA and cardiology testing/clearance.
    • Heart – same as above plus exercise testing inclusive of (MVO2) and NYHA class.
    • Lung – same as above.
    • Pancreas – same as above.
    • Intestine/Multivisceral-no additional testing
    • Stem cell – same as above, plus performance score and documentation of donor identification for allogeneic stem cell.
  4. Annual dental clearance.
  5. Routine health screening exams as per standards of care (mammograms, Pap, and/or colonoscopy).
  6. Appropriate comorbidity testing/clearance, including cardiology.
  7. Serum or Urine Drug screen results (within 90 days of request)
  8. Infectious disease screening:
    • CMV, EBV, VZV within one year unless baseline IgG antibody positive.
    • Hepatitis A within one year, unless baseline antibody positive
    • Hepatitis B testing within one year, unless baseline surface antibody positive.
    • Hepatitis C within one year, unless baseline positive (viral load required within three months if positive).
    • RPR within one year.
    • HIV within one year, unless baseline positive (CD4 count and viral load required within three months if positive).
    • Toxoplasma titer for heart transplant recipients.
    • Results of annual PPD, T-Spot, or QuantiFERON for all solid organ transplants, unless previously positive.
  9. Detailed psychosocial evaluation within 6 months.
  10. UNOS validation is required for transplant listing extension.
  11. Continuity of care - Submit documentation validating previous listing approval plus a copy of the current UNOS listing.