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.

  • 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 7 calendar days when additional information is required (pharmacy and medical).
  • To ensure a timely response to your request, submit all prior authorization requests at least 7 days in advance with all required information.
  • A prior authorization request must include the following:

    • Current, applicable codes may include:
    • Current Procedural Terminology (CPT)
    • International Classification of Diseases, 9th Edition (ICD-9, AS OF 10/01/2015 THIS MUST BE ICD-10 CODES)
    • Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes
    • National Drug Code (NDC)
    • Name, date of birth, sex, and identification number of the member
    • Primary care provider or treating practitioner
    • Name, address, phone and fax number and signature, if applicable, of the referring practitioner or provider
    • Name, address, phone and fax number of the consulting practitioner or provider
    • Problem/diagnosis, including the ICD-9 code (AS OF 10/01/2015 THIS MUST BE ICD-10 CODES)
    • Reason for the request
    • Presentation of supporting objective clinical information, such as clinical notes, laboratory and imaging studies, and treatment dates, as applicable for the request

    All clinical information must be submitted with the original request.

    Nonparticipating providers must obtain prior authorization before rendering any service other than emergency and self-referral services.
  • Services that require prior authorization will be reimbursed only if prior authorization has been obtained.
  • Prior authorization requests can be submitted via the web (outpatient services only), phone and fax.
  • New authorization requests for oncology and radiation treatment should go through eviti® at www.eviti.com.
  • In conjunction with the member handbook to determine benefits, registered providers should utilize the MPC Prior Authorization Lookup Tool to determine prior authorization requirements.
  • All laboratory and radiology services should be performed in a free-standing facility as clinically appropriate. Please note that only laboratory/radiology services listed as requiring authorization in the prior auth look-up tool will be reviewed for prior authorization. Exceptions to the rule are included in the laboratory and radiology correspondence attached below.
  • Certain gastroenterology and urology procedures performed in a hospital outpatient facility require prior authorization.  Where access to these facilities is available, these procedures should be performed in free-standing Ambulatory Surgery Centers (ASC’s).  Exceptions to the rule are included in the ASC change announcement attached below.

You can reach MPC’s Prior Authorization Department at 1-800-953-8854.

Maryland Physicians Care has contracted with National Imaging Associates (NIA), an affiliate of Magellan Health Services, for high tech radiology services. The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. NIA manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities. You can request authorization via web at www.RadMD.com or by phone at 1-800-424-4836.

Prior authorization is required for the following outpatient radiology procedures:

  • CT/CTA
  • MRI/MRA

To request a peer to peer regarding a Prior Authorization denial  call  800-953-8854.  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 OR 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.