CurrentMedStar Family Choice MarylandPolicy 115

Utilization Management (UM) Criteria

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This policy governs the criteria and processes MedStar Family Choice uses to make utilization management decisions for Maryland members, including preauthorization, retrospective review, concurrent review, pharmacy requests, emergency care, and requests for UM criteria.

Policy Summary

PayerMedStar Family Choice Maryland

PolicyUtilization Management (UM) Criteria

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit Wegovy requests with the completed Wegovy Prior Authorization Form available on the MedStar Family Choice website.

SourceLink

POLICY UPDATE CHANGES

Regulatory references were updated to reflect the 2026 NCQA standards.

The pharmacy section removed the reference to Synagis requiring prior authorization.

Wegovy requests now require completion of a Wegovy Prior Authorization Form available on the MedStar Family Choice website.

The reference to the Hepatitis C Memorandum was removed as no longer applicable.

2 business daysTarget processing time for a complete, nonurgent preauthorization request

14 daysMaximum time for a final preauthorization decision

24 hours

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CurrentMedStar Family Choice MarylandPolicy 115

Utilization Management (UM) Criteria

Customize your policy alerts

Sign up for medstarfamilychoicemaryland Policy 115 alerts

Get alerted when Policy 115 changes without checking for updates manually.

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Policy Summary

PayerMedStar Family Choice Maryland

PolicyUtilization Management (UM) Criteria

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit Wegovy requests with the completed Wegovy Prior Authorization Form available on the MedStar Family Choice website.

SourceLink

POLICY UPDATE CHANGES

Regulatory references were updated to reflect the 2026 NCQA standards.

The pharmacy section removed the reference to Synagis requiring prior authorization.

Wegovy requests now require completion of a Wegovy Prior Authorization Form available on the MedStar Family Choice website.

The reference to the Hepatitis C Memorandum was removed as no longer applicable.

2 business daysTarget processing time for a complete, nonurgent preauthorization request

14 daysMaximum time for a final preauthorization decision

24 hours

Decision timeframe for covered outpatient pre-service and concurrent pharmacy authorization requests

8:30 AM–5:00 PMTelephone availability for requesting criteria or discussing UM decisions

800-905-1722 / 410-933-2200Utilization management contact numbers

Utilization Management Coverage Criteria

Applicable UM criteria sources

UM decisions may be based on all applicable criteria sources.

Applicable UM criteria source: The reviewing team may apply MedStar Family Choice protocols; MedStar Family Choice pharmacy policies and procedures; InterQual; Medicare or Medicaid guidelines, including Maryland Department of Health transmittals, Local Coverage Determinations, National Coverage Determinations, Local Coverage Articles, and CMS State Medicaid Director Letters; COMAR; CFR; MedStar Family Choice MCO benefit coverage; the Provider Manual; the Member Handbook; FDA approval; Maryland Medicaid approved item lists and fee schedules; network availability; the Continuity of Care Policy; the UM Criteria Policy; national and international professional medical society guidelines; USPSTF guidance; prevailing medical literature when guidelines are absent; the HealthChoice Diabetes Prevention Program Manual; and Maryland Department of Health Medicaid rules.

The specific sources used depend on the service under review.

Initial preauthorization

Preauthorization is evaluated using the applicable medical-necessity and coverage criteria.

Preauthorization review: The request must include the appropriate ICD-10, CPT, and HCPCS codes and supporting clinical information; the requested service must meet applicable medical-necessity criteria; and Managed Care Organization enrollment and coverage must exist.

MedStar Family Choice may direct services to participating providers and facilities. Out-of-network services may require approval based on network availability and continuity of care.

Continuation therapy

Ongoing services are covered only when continued treatment remains medically necessary.

Continuation of services: The ongoing service or treatment must continue to meet applicable medical-necessity criteria and must demonstrate improvement in the member's condition or benefit to the member.

Requests without demonstrated improvement or member benefit are subject to denial as not medically necessary.

Concurrent review

Concurrent review evaluates the appropriateness and timeliness of ongoing care.

Concurrent review: The service must meet applicable InterQual, Medicare and Medicaid, COMAR, MedStar Family Choice benefit-coverage, and network-availability criteria; clinical documentation must support timely care and the appropriate level of care.

Medical Directors may issue clinical denials when delayed care or discharge planning creates an inpatient day that could have been avoided if care had been provided timely. Inpatient days that do not meet medical-necessity criteria are the responsibility of the inpatient facility.

Emergency services

Emergency department claims are paid when the emergency-care requirements are met.

Emergency care: The request must involve an emergency medical condition or active labor; the emergency department must perform and document a medical screening examination; and the services must satisfy the prudent-layperson standard and applicable treatment-level review.

A nurse examination or triage information alone is not considered evidence of a medical screening examination. Emergency department documentation is reviewed for the medical screening examination, prudent-layperson standard, and assigned treatment level under HSCRC reasonable Clinical Care Time guidelines.

Services carved out to Maryland Medicaid are not the liability of the MedStar Family Choice MCO and are subject to administrative denial. These services include behavioral health care, including mental health and substance abuse services, as well as certain durable medical equipment (DME) and pediatric outpatient rehabilitation services.

Services and codes not listed on the applicable Maryland Medicaid approved lists or fee schedules are not considered covered benefits and will be denied. These sources include the Maryland Medicaid DMS/DME Approved List of Items, Medical Laboratory Fee Schedule, Audiology Fee Schedule, and Professional Services Program Approved List of Items.

Requests for ongoing services or treatment may be denied as not medically necessary when the treatment has not demonstrated improvement in the member’s condition or a benefit to the member. Continued services must remain medically necessary and show meaningful member benefit.

Inpatient days that do not meet applicable medical-necessity criteria may be denied and assigned to the inpatient facility. This includes days that could have been avoided through timely care or discharge planning, such as when delays in care or discharge planning create an avoidable inpatient day.

Coding Requirements

Codes required for preauthorization requestsmixed

ICD-10	Diagnosis codes required on preauthorization requests
CPT	Procedure codes required on preauthorization requests
HCPCS	Healthcare Common Procedure Coding System codes required on preauthorization requests

Provider Submission and Denial-Risk Guidance

Prior Authorization

Submit complete preauthorization requests

Submit the appropriate diagnosis and procedure codes, supporting clinical information, and the applicable referral or prior authorization form for services requiring preauthorization.

Include all appropriate ICD-10, CPT, and HCPCS codes.
Use the Maryland Uniform Consultation Referral Form or MedStar Family Choice Prior Authorization Form, with clinical information attached, when applicable.

Prior Authorization

Complete the Hepatitis C medication form

Requests for Hepatitis C medications require a completed Hepatitis C Therapy PriorAuthorization Form and Prescription. The form is available on the MedStar Family Choice website.

Prior Authorization

Policy Background

MedStar Family Choice uses documented utilization management criteria to promote consistent, appropriate, and evidence-based decisions. Reviews consider the appropriateness of care, whether coverage exists, and whether the requested service is medically necessary, using applicable plan policies, benefit coverage, regulatory requirements, clinical guidelines, and relevant medical literature.

Emergency Care Definitions

Emergency medical condition

Acute symptomsA medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain.

Expected consequenceA prudent layperson with average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention would place the individual, or a pregnant woman or her unborn child, in serious jeopardy.

Potential impairmentThe absence of immediate medical attention could seriously impair bodily functions or cause serious dysfunction of any bodily organ or part.

Prudent layperson standard

Basis of evaluationEmergency services are evaluated based on what a prudent layperson with average knowledge of health and medicine could reasonably expect.

Immediate attention

Policy Summary

PayerMedStar Family Choice Maryland

PolicyUtilization Management (UM) Criteria

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit Wegovy requests with the completed Wegovy Prior Authorization Form available on the MedStar Family Choice website.

SourceLink

On This Page

Submit the required Opioid DUR form

Requests for medications listed in the Maryland Department of Health Opioid DUR require a completed prior authorization form.

This includes high-dose or long-acting narcotics, methadone for pain, and fentanyl.
MedStar Family Choice accepts its form or the universal form developed by the Maryland Department of Health and Maryland MCOs.

Prior Authorization

Complete the Wegovy prior authorization form

Requests for Wegovy require a completed Wegovy Prior Authorization Form, available on the MedStar Family Choice website.

Step Therapy

Document formulary alternatives

For a non-formulary medication, support the medical need for the specific medication and provide documentation of prior use of available formulary medications when applicable.

Documentation Required

Include complete clinical documentation

Preauthorization requests must include all appropriate ICD-10, CPT, and HCPCS codes together with supporting clinical information.

Requests may be submitted on the Maryland Uniform Consultation Referral Form or the MedStar Family Choice Prior Authorization Form with clinical information attached.

Documentation Required

Support non-formulary medication requests

Non-formulary medication requests must include clinical documentation supporting the medical need for the specific medication and, when applicable, documentation of prior use of available formulary medications.

Documentation Required

Document emergency department evaluation

Emergency department documentation is reviewed for evidence of a medical screening examination, application of the prudent-layperson standard, and the assigned treatment level under HSCRC guidelines for reasonable Clinical Care Time.

A nurse examination or triage information alone is not considered evidence of a medical screening examination.
Document the examination and clinical information supporting emergency treatment.

Denial Risk

Retrospective approval is not guaranteed

Retrospective requests are reviewed against the applicable utilization management criteria and are not guaranteed for approval. Retrospective services that could have been provided within the network are unlikely to be approved unless the care was urgent or emergent, a COMAR-defined self-referral service, or involved continuity of care.

Denial Risk

Match the claim to the services provided

Requests for payment are subject to denial when the claim does not match the clinical services provided.

Denial Risk

Demonstrate ongoing improvement or benefit

Ongoing services or treatment that do not demonstrate improvement in the member’s condition or benefit to the member may be denied as not medically necessary.

Denial Risk

Verify services and codes are on approved lists

Services or codes not listed on the Maryland Medicaid DMS/DME approved List of Items, Medical Laboratory or Audiology Fee Schedule, or Professional Services Program Approved List of Items are not considered covered benefits and will be denied.

Denial Risk

Identify carved-out services

Services carved out to Maryland Medicaid, including behavioral health care and certain DME or pediatric outpatient rehabilitation services, are subject to administrative denial because they are not the liability of the MCO.

Behavioral health care includes mental health and substance abuse services.
Confirm the responsible Maryland Medicaid program before submitting the request.

Denial Risk

Avoid non-medically necessary inpatient days

Inpatient days that do not meet applicable medical-necessity criteria may be denied and assigned to the inpatient facility, including days that could have been avoided through timely care or discharge planning.

Document timely care and the appropriate level of care.
The inpatient facility is responsible for timely and appropriate discharge planning.

The standard considers whether the circumstances could reasonably indicate a need for immediate medical attention.

Emergency-care applicationMedStar Family Choice uses the prudent layperson standard when paying for emergency services, consistent with the Balanced Budget Act of 1997.