Maryland MD

Maryland Medicaid FFS prior authorization is CENTRALIZED at MDH (not delegated to MCOs for FFS scope). The authority publishes (1) a single master code list "Professional Services Codes Requiring Preauthorization" (.xls, rev 07.31.25) enumerating every HCPCS/CPT requiring preauth, and (2) a library of per-procedure/per-drug Clinical Criteria PDFs split across two index pages (Drugs & Injectables; Surgical Procedures). Submission is fax (mdh.preauthfax@maryland.gov) using service-specific Preauthorization Request Forms; eMedicaid/ePREP portal for provider enrollment. HealthChoice managed-care PA is delegated to the members MCO (9 plans). PHARMACY uses a state-administered Common Formulary across all HealthChoice MCOs. BEHAVIORAL HEALTH (specialty MH+SUD) is CARVED OUT of HealthChoice to the Public Behavioral Health System (PBHS), a statewide ASO. NOTE: PBHS ASO has transitioned from Optum Maryland to CARELON (maryland.carelonbh.com) - state_meta still lists Optum. Dead pins: pa_index (Prior-Auth.aspx), pharmacy (Pharmacy-Program.aspx), healthchoice (HealthChoice.aspx) all 404; live replacements recorded in repin_candidates.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: None. Next due: 2026-12-31 (CY 2026 MCO contract). Contracts extended through: CY 2026 HealthChoice MCO Agreement signed 2025-09-23.

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## 1. How MD requires PA Maryland Medicaid's prior authorization (PA) requirements are centralized and managed by the Maryland Department of Health (MDH). The process involves specific criteria that providers must meet to obtain approval for certain services or drugs. Key documents include: - **Professional Services Codes Requiring Preauthorization**: A master code list (.xls) enumerating HCPCS/CPT codes requiring preauth. - **Clinical Criteria PDFs**: Detailed clinical criteria for specific procedures and medications, such as gender-affirming treatments, bariatric surgery, hyperbaric oxygen therapy, biomarker tests, out-of-state inpatient admissions, and blepharoplasty. Providers submit PA requests via fax or a centralized portal. Specific forms are used for different service types: - **Injectable Drugs Preauth Form**: For physician-administered injectable drugs. - **Physicians Preauth Form**: For physician services, requiring detailed clinical justification and documentation. ## 2. How MD publishes and reports PA Maryland Medicaid publishes its PA requirements through various channels: - **Provider Manuals and Websites**: The Maryland HealthChoice / MMCP website (e.g., Provider-Information.aspx) hosts documents like the Professional Services Codes Requiring Preauthorization and specific clinical-criteria PDFs. - **Portal + Fax**: MDH uses a portal for submissions, though some forms still require faxing. Reporting on PA decisions is less detailed in the source documents; providers receive notifications regarding PA status (channel specifics not enumerated in the corpus). ## 3. MD's CMS-0057-F and PA-reform compliance posture The source documents do not explicitly state Maryland's CMS-0057-F posture. The state appears oriented toward federal-aligned transparency through its centralized criteria library and clinical-criteria PDFs. Maryland uses a hybrid carve-out model — behavioral health carved out to an ASO and long-term services and supports (LTSS) carved out to state FFS — implying a nuanced PA-reform approach balancing centralization with carve-outs. Maryland is **not** a WISeR state. (WISeR = the federal "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — not Maryland.) No WISeR participation should be inferred for MD. ## 4. How MD runs its own program Maryland Medicaid's program is structured around several key components: - **Centralized Criteria Library**: MDH maintains a centralized library of PA codes and clinical criteria, ensuring uniform standards. - **Behavioral Health Carve-Out**: Behavioral health services are carved out to an Administrative Services Organization (ASO), which manages its own PA processes. - **LTSS Carve-Out**: LTSS services are managed through state Fee-for-Service (FFS). - **Fiscal Agents**: The program has transitioned fiscal agents from ACS-Inc to Conduent/Gainwell. The Maryland HealthChoice §1115 Demonstration waiver plays a significant role and may influence PA processes through its service-delivery models. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Centralized Criteria**: A centralized criteria library promotes consistency across providers. - **Specific Clinical Criteria**: Detailed clinical criteria for specific procedures and medications support medical-necessity review. ### Missing/Uncertain: - **CMS-0057-F Compliance**: No explicit information in the corpus. - **Gold Card Law**: Status unspecified in the source documents. - **Foster Care Program**: No specific foster-care MCO program is mentioned. - **Effective Dates and Revisions**: Some documents specify effective dates (e.g., Oct. 1, 2025); others do not, creating uncertainty about currency. Overall, Maryland's PA system is robust in its centralized approach but lacks clarity on certain compliance measures and program details.