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Medical Prior Authorization

Prior authorization is one way Maryland Physicians Care monitors the medical necessity and cost-effectiveness of our members’ services. 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.

Effective 4/1/21, the following Prior Authorization form will be required for all prior authorization submissions to Maryland Physicians Care.

Prior Authorization Process

  • All elective hospital admissions require prior authorization.
  • The state-mandated turnaround time for PA requests is two 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.

Notes:

  • 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. View form here.
  • Remote Monitoring requests require the MDH Remote Monitoring form with the clinical information. View forms here.
  • Organ and Stem Cell Transplant Evaluations require the Prior Authorization form and clinical information (see Transplant Evaluation Checklist).
  • Organ and Stem Cell Transplant Listings require the Prior Authorization form and clinical information (see Transplant Listing Checklist).

Coverage of Emergency and Post Stabilization Services

MPC does not retrospectively deny emergency services solely based upon discharge diagnoses only. The claims system automatically processes claims for emergency services to screen and stabilize a member.

MPC defines the process to screen and stabilize a member to be when the onset of the medical condition that manifested itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the member at risk. MPC defines post stabilization services as services related to an emergency medical condition that are provided after an enrollee is stabilized to maintain the stabilized condition, or under the circumstances described in §42 CFR 438.114(e) to improve or resolve the enrollee’s condition. The member is not subject to restrictions on the use of a particular provider or penalties for use of a non-participating provider.

Although it is strongly encouraged, MPC will not withhold payment for emergency services based on whether the emergency room provider, hospital or fiscal agent notifies the enrollee’s primary care provider or MCO of the enrollee’s screening and treatment within 10 calendar days of presentation for emergency services.

MPC does not bind the determination of the attending emergency physician, or the provider actually treating the enrollee, for who is responsible in determining when the enrollee is sufficiently stabilized for transfer or discharge as responsible for coverage and payment.

Notifications

Peer-To-Peer Process

The Peer-to-Peer Process is available to any provider who is rendered a medical necessity denial. The intent of the Peer-to-Peer is to discuss the denial decision. To request a Peer-to-Peer regarding a denial call, please call 410-412-8297 and leave the following information:

  • Provider name
  • Provider phone number
  • Provider’s available date and time(s) (please note: Peer-to-Peers cannot be scheduled more than three (3) business days from the Peer-to-Peer request)
  • Member name
  • Member DOB
  • Authorization #
  • The caller’s contact information

The provider/facility must request the peer-to-peer within two (2) business days of the initial notification of the denial.

Maryland Physicians Care has three (3) business days to respond to Peer-to-Peer requests.

If the MPC Medical Director returns the Peer-to-Peer request and leaves a message, the provider has two (2) business days to return the call, or the denial will be upheld and the provider will need to file an appeal.

For Pharmacy or Medication Peer-to-Peer requests, please contact Express Scripts at 800-753-2851.

Transplant Services Required Clinical Information Guide

All transplant services listed below require prior authorization. Please utilize the Transplant Evaluation and Listing checklists to ensure all required information is submitted along with the prior authorization request form to avoid delay in review. Submit all forms and clinical information via fax to 800-953-8856.

Transplant Evaluation

  • Letter of medical necessity and appropriate PA form.
  • Routine complete history and physical (including pertinent routine social history) within six months.
  • Basic labs (chemistries, CBC, and liver function tests) within six 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

  • Letter of medical necessity from a transplant service physician
  • Routine complete history and physical within six months.
  • Basic labs (chemistries, CBC, and liver function tests) within six 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.
  • Annual dental clearance.
  • Routine health screening exams as per standards of care (mammograms, Pap, and/or colonoscopy).
  • Appropriate comorbidity testing/clearance, including cardiology.
  • Serum or Urine Drug screen results (within 90 days of request)
  • 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.
  • Detailed psychosocial evaluation within six months.
  • UNOS validation is required for transplant listing extension.
  • Continuity of care – Submit documentation validating previous listing approval plus a copy of the current UNOS listing.

Know The Facts About Coronavirus (COVID-19)

Symptoms are flu-like, including: fever, coughing, and shortness of breath.

If you think you might have been exposed, contact your doctor immediately. You can also have a video visit with a doctor using the MyVirtualMPC app.

It is important to do everything you can to protect yourself from COVID-19.