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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyBeacon Health Options PRP Claims Update | OpenPaye…
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    CurrentBeacon-Health-OptionsPolicy N/A

    Psychiatric Rehabilitation Program Referring Provider Requirements

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    This policy governs Maryland Medicaid Psychiatric Rehabilitation Program claims and requires providers to submit an individual referring practitioner's NPI and verify active Maryland Medicaid enrollment on the date of service. It applies to PRP providers and referring licensed mental health professionals in Maryland.

    Policy Summary
    PayerBeacon-Health-Options
    PolicyPsychiatric Rehabilitation Program Referring Provider Requirements
    Policy CodePolicy N/A
    Change TypeRevised and added requirements
    Effective DateJanuary 1, 2026
    Next Review DateN/A
    Key ActionSubmit the individual referring practitioner's NPI in Field 17b and verify active Maryland Medicaid enrollment for every monthly PRP claim.
    SourceLink
    POLICY UPDATE CHANGES

    Effective January 1, 2026, PRP providers must submit the referring practitioner's NPI and verify the practitioner's active Maryland Medicaid enrollment for monthly claims submissions.

    Maryland Medicaid will deny PRP claims when the referring practitioner is not actively enrolled on the date of service or when the claim does not contain a valid individual referring practitioner's NPI.

    Jan 1, 2026Claim denial requirements begin
    17bReferring provider field
    Individual NPIRequired identifier
    Policy Summary
    PayerBeacon-Health-Options
    PolicyPsychiatric Rehabilitation Program Referring Provider Requirements
    Policy CodePolicy N/A
    Change TypeRevised and added requirements
    Effective DateJanuary 1, 2026
    Next Review DateN/A
    Key ActionSubmit the individual referring practitioner's NPI in Field 17b and verify active Maryland Medicaid enrollment for every monthly PRP claim.
    SourceLink
    On This Page
    PRP Claim Reimbursement RequirementsClaim Submission RequirementsProvider Compliance ActionsKey Terms

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    42 CFR § 455.440Federal requirement
    2State provisions cited

    PRP Claim Reimbursement Requirements

    PRP Claim Reimbursement Requirements

    To receive payment for PRP services for dates of service beginning January 1, 2026, all of the following requirements must be met:

    ALL of the following

    • Referral and enrollment

      • The individual was referred for PRP services by a licensed mental health professional.
      • The referring practitioner was enrolled as a Maryland Medicaid provider and actively enrolled on the date of service.

    • Claim reporting

      • The claim includes the NPI of the individual referring practitioner in the Referring Provider field, Field 17b.
      • The referring provider NPI is an individual practitioner NPI; a group or facility NPI is not acceptable and the claim is not reimbursable.

    Claim Submission Requirements

    Claim denial effective date
    Effective dateDates of service beginning January 1, 2026
    Applies toPsychiatric Rehabilitation Program (PRP) claims
    Denial conditionClaims may be denied when the referring practitioner is not actively enrolled with Maryland Medicaid on the date of service
    Referring provider claim field
    Claim fieldReferring Provider field, Field 17b
    Required entryThe NPI of the individual referring practitioner
    Unacceptable entry

    Provider Compliance Actions

    Documentation Required

    Verify referring practitioner enrollment

    For all monthly PRP claims submissions, submit the National Provider Identifier (NPI) of the individual referring practitioner and verify that the practitioner has active Maryland Medicaid enrollment.

    Prior Authorization

    Use an eligible referring practitioner

    Ensure that each individual receiving PRP services was referred by a licensed mental health professional who is enrolled as a Maryland Medicaid provider and has active status on the date of service.

    Key Terms

    Eligible referring practitioner
    DefinitionA licensed mental health professional who refers an individual for PRP services
    EnrollmentEnrolled as a Maryland Medicaid provider
    Required statusActive status on the date of service
    Acceptable referring provider NPI
    DefinitionThe NPI of an individual referring practitioner
    Claim locationEntered in the Referring Provider field, Field 17b
    Not acceptableA group or facility NPI does not satisfy the requirement
    A group or facility NPI
    Billing Rule

    Report the individual referring NPI

    Enter the individual referring practitioner's NPI in the Referring Provider field, Field 17b. Do not submit a group or facility NPI.

    Denial Risk

    Avoid claim denial

    PRP claims for dates of service beginning January 1, 2026 may be denied when the referring practitioner is not actively enrolled with Maryland Medicaid on the date of service or when the referring provider field does not contain a valid individual NPI.

    Documentation Required

    Check enrollment status

    Use the Provider Verification System to verify the referring practitioner's Maryland Medicaid enrollment status before submitting the claim.