Cover medically necessary State Plan services

MCOs must cover medically necessary State Plan services per COMAR 10.67.06 and applicable federal rules; this includes services the MCO voluntarily agrees to provide and services necessary for compliance with subpart K of 42 CFR Part 438.

Service authorization policies and procedures

Maintain written policies and procedures for processing initial and continuing authorizations, ensure consistent application of review criteria (including specialist consultations), and adhere to service authorization and notification requirements in 42 CFR 438.210(d) and COMAR.

• Have mechanisms to ensure consistent application of authorization review criteria, including specialist consultation where appropriate.
• Adhere to service authorization and notification requirements in 42 CFR 438.210(d) and COMAR 10.67.09.04.

Adverse determinations for gender-affirming care require specialist review

Do not issue an adverse benefit determination denying or limiting gender-affirming treatment unless a health care provider experienced in prescribing or delivering gender-affirming treatment has reviewed and confirmed the appropriateness of the adverse determination.

Implement opioid DUR edits and retrospective monitoring

Implement opioid prospective and retrospective DUR edits: prospective limits on days' supply (initial fills), quantity, duplicate therapy, early refills, and maximum daily MME; and an automated retrospective claims review to detect fills exceeding prospective limits or concerning co-prescribing patterns.

• Prospective safety edits for initial and subsequent opioid fills (days' supply, quantity, duplicate therapy, early refills).
• Prospective limits on maximum daily morphine milligram equivalents for initial and subsequent fills.
• Automated retrospective claims review to identify fills exceeding limits or patterns of inappropriate prescribing/co-prescribing.

Risk of payment denial after sanctions

Payments for new Enrollees may be denied following imposition of sanctions when MDH determines the MCO acted or failed to act per 42 CFR §438.700(b)-(d); payments remain denied until CMS or MDH is satisfied the reason no longer exists.

Limited data set creation and Data Use Agreement required

If directed in writing, Business Associate may create a limited data set (per 45 C.F.R. §164.514(e)(2)) but must enter into a HIPAA-compliant Data Use Agreement with recipients and report any material breach of that Data Use Agreement to the Covered Entity immediately after becoming aware.

Notify Covered Entity of PHI breaches/security incidents within 15 days

Report any unauthorized use or disclosure of PHI, including breaches of unsecured PHI and security incidents, to the Covered Entity without unreasonable delay and no later than 15 calendar days after becoming aware; include required details and follow the breach notification form/procedures.

• Notify Covered Entity no later than 15 calendar days after discovery of a use/disclosure not permitted by the Agreement.
• Provide required breach details (description, dates, counts, types of PHI, mitigation steps, contact information) using the MDH breach notification form.

Reimburse out-of-network FQHC emergent services (documentation required)

Reimburse out-of-network FQHCs for on-site emergent services when the FQHC participates in Medical Assistance, lacks an MCO contract, verifies the PCP cannot see the enrollee timely, and provides required documentation; MCOs may require and deny reimbursement if documentation is not provided. Reimbursement rate is per COMAR 10.67.04.21 with Program payment of the difference per COMAR 10.09.08.05-1.

Use MDH breach notification form to notify Covered Entity

Use MDH's prescribed breach notification form to notify MDH of breaches of unsecured PHI, providing description of the breach, dates, number of individuals affected, types of PHI involved, mitigation actions, and contact information.

Submit Service Area participation or voluntary freeze requests to MDH

Express intent to Open, Request to Open, or Request a Voluntary Freeze for Service Areas during the Agreement term; requests are subject to MDH review and approval, and MDH approval of a voluntary freeze does not relieve the MCO's obligation to accept enrollees who select the MCO.

Follow credentialing, panel limits, and provider screening requirements

Ensure networks meet COMAR 10.67.05: maintain adequate number, mix, and geographic distribution; limit in‑plan practitioner FTE panels to no more than a 200:1 enrollee-to-practitioner ratio; screen/enroll/revalidate providers per 42 CFR part 455; accept Maryland Uniform Credentialing Form; and refrain from contracting with excluded providers.

• Assign in‑plan individual practitioners no more than a 200:1 enrollee-to-practitioner ratio (FTE basis).
• Screen, enroll, and revalidate network providers per 42 CFR part 455 and verify against MDH fee-for-service provider file.
• Accept the Maryland Uniform Credentialing Form and follow MDH provider manual template.
• Do not contract with providers terminated or excluded from the Program.

Demonstrate 90% coverage or face auto‑assignment freezes

When the MCO cannot demonstrate adequate coverage for 90% of enrollees in a service area at the required time or distance standards, MDH may freeze auto-assignments; MCOs proposing expansion must demonstrate 90% coverage at required time/distance for each provider type to open in a new county.

MOM case management duties and documented outreach protocol

MOM case managers must perform intake, assessment, treatment planning, coordination, referrals, and monthly substantive outreach; substantial outreach requires at least three documented outreach attempts per month, two of which must use different modalities.

• Conduct standardized intake and assessments and develop individualized treatment plans.
• Provide monthly substantive outreach and document at least three outreach attempts per month during substantial outreach, with two different modalities.

Complete MLR worksheets, attestations, and supporting exhibits

Complete MLR reporting worksheets and attestation (certified by CFO or Administrator), include the audited underwriting exhibit for HealthChoice experience where applicable, and provide documentation of expense allocation methodology per 42 CFR §438.8; submit reports by MDH deadlines (MLR report due September 1 following the incurred period).

Quarterly M-QIP payment flows and reimbursement to FPI

M-QIP payments apply to eligible providers employed by or affiliated with Faculty Physicians Inc. (FPI); MCOs contracted with FPI will receive quarterly payments from MDH and are required to reimburse FPI according to MDH's schedule.

DPP billing codes, modifiers, and MCO responsibilities for high-cost drugs

Bill required HCPCS G-codes for DPP sessions and performance payments (examples: G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9880, G9881, G9891) and use make-up modifiers TS for in‑person and VM for virtual sessions (do not combine GT with VM or TS); MCOs must authorize, manage, and pay claims for High-Cost Low Volume drugs and invoice MDH quarterly for incurred expenses.

• Use TS for in‑person make-up sessions and VM for virtual make-up sessions; do not use GT with VM or GT with TS.
• Use attendance tracking code G9891 as non-payable tracking when appropriate.
• MCOs authorize and pay claims for listed high-cost low-volume drugs and invoice MDH quarterly for those expenses.

Use listed HCPCS codes for high-cost, low‑volume drugs

High-cost low-volume drugs are listed with multiple HCPCS codes (examples include J1426, J7195, J9039, J8499, J0598, J9348); MCOs must use these HCPCS where applicable when billing for covered products.

• Examples of HCPCS associated with listed products: J1426, J7195, J9039, J8499, J0598, J9348.

Ensure billing with referenced HCPCS (J9039, J8499, J0598, J9348)

The policy references HCPCS codes J9039, J8499, J0598, and J9348 for applicable high‑cost low‑volume drugs; ensure claims for these products use the referenced HCPCS when applicable.

Bill J7195/J9039/J8499/J0598/J9348 where applicable

HCPCS codes including J7195, J9039, J8499, J0598, and J9348 are listed in the drug exhibits; use these codes for the associated drugs when submitting claims.

Follow prior auth, payment, and invoicing procedures for listed HCPCS

The High‑Cost Low‑Volume list includes HCPCS codes (e.g., J9039, J8499, J0598, J9348) that may be subject to prior authorization and MDH invoicing rules; follow the Agreement's authorization, payment, and invoicing procedures for these items.

Use documented drug ↔ NDC ↔ HCPCS mappings when billing

Follow the drug-to-code mappings in the exhibit: where available, drugs are paired with NDCs and HCPCS (examples: Blincyto 55513-0160-01 → J9039; Bylvay 74528-0040-01 → J8499; Cinryze 42227-0081-05 → J0598; Danyelza 73042-0201-01 → J9348).

Recognize listed J‑codes (J3490, J3590) in the drug exhibit

The listing includes miscellaneous J-codes (J3490, J3590) among HCPCS/J-code entries; if using these unspecified J‑codes, ensure alignment with the Agreement's exhibit and billing guidance.