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 Accordion Name : Annual QA Activities (10)
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| Annual QA Activities | Annual Technical Reports | | 1 |
| Annual QA Activities | 2026 | | 2 |
| Annual QA Activities | 2025 | | 3 |
| Annual QA Activities | 2024 | | 4 |
| Annual QA Activities | 2023 | | 5 |
| Annual QA Activities | 2022 | | 6 |
| Annual QA Activities | 2021 | | 7 |
| Annual QA Activities | 2020 | | 8 |
| Annual QA Activities | 2019 | | 9 |
| Annual QA Activities | 2018 | | 10 |
| Accordion Name : Award Forums (2)
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| Award Forums | Annual Reports | | 1 |
| Award Forums | Summary Reports 2017-2021 | | 2 |
| Accordion Name : BH FAQ (8)
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| BH FAQ | Who typically provides specialty behavioral health services? | Maryland Medicaid fee-for-service specialty behavioral health providers include: - Licensed Clinical Professional Counselors
- Licensed Clinical Social Workers
- Psychiatric Nurse Practitioners
- Psychiatrists
- Psychologists
- Specialty mental health and community-based substance use disorder treatment programs licensed by the Behavioral Health Administration
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| BH FAQ | Who can provide primary behavioral health services? | Maryland Medicaid primary care providers who can provide primary behavioral health services include: - Doctors - Including pediatricians, family medicine practitioners, and internists
- Nurse Practitioners
- Physician's Assistants
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| BH FAQ | How can a behavioral health specialist bill Medicaid for specialty behavioral health services provided to a Medicaid HealthChoice member? | The specialist must enroll with Medicaid through ePREP and register with Carelon to receive payment for services.
After registering with Carelon, the specialist can request preauthorizations and receive reimbursements for Medicaid-covered services directly through them.
The specialist will bill Carelon for services using behavioral/mental health diagnosis codes. Use the diagnosis codes listed in COMAR 10.67.08.02 M or N and Current Procedural TerminologyⓇ (CPT) codes associated with your provider type on the Public Behavioral Health System fee schedules, for example psychotherapy, medication management, behavioral health counseling.
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| BH FAQ | How can a Medicaid managed care primary care provider bill Medicaid for primary behavioral health services provided to a HealthChoice member? | Providers must enroll with Medicaid through ePREP and participate with the patient’s managed care organization to receive payment for services.
Primary care providers should bill the patient’s managed care organization for primary behavioral health services. Use the procedure codes normally used by primary care providers, for example, the 9920x series. The diagnosis may be a mental health diagnosis, such as the “F” series. For more information see COMAR 10.67.08.02 or Carelon Provider Resources and Support.
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| BH FAQ | How can a Medicaid Advanced Practice Professional (APP) bill for primary or specialty behavioral health services? | How to Bill Primary Care - For APPs, such as nurse practitioners or physician’s assistants, bill for primary care services, including primary behavioral health care, within the scope of primary care to the patient’s HealthChoice managed organization.
How to Bill Specialty Care - For APPs working under the scope of a specialty behavioral health service, like psychiatry or neuropsychiatry, bill specialty behavioral health care to Carelon. Providers must be a specialty mental health provider that meets the requirements in COMAR 10.09.59.04.
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| BH FAQ | How does a behavioral health specialist in a primary care practice bill for services? | Behavioral health specialists may provide services in primary care practices if participating in the Maryland Collaborative Care Model. The Maryland Collaborative Care Model (CoCM) is a patient-centered, evidence-based approach to integrate physical and behavioral health services in primary care settings. PCP-led teams of qualified professionals are eligible to receive reimbursement for CoCM services. These teams include a PCP, a behavioral health care manager, and a psychiatric consultant.
To participate in CoCM, providers must enroll with Medicaid through ePREP and participate with the patient’s managed care organization to receive payment for services.
The primary care provider bills the MCO for reimbursement under their name, provider number, and the practice’s tax identification number. For more information, see PT 26-24, Coverage of Collaborative Care Model Statewide for HealthChoice and Medicaid Fee-For Service Enrollees, Effective October 1, 2023.
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| BH FAQ | Who pays a claim for psychological testing and evaluation services for a Medicaid member? | It depends on the diagnosis or if it is a preauthorization requirement.
When a licensed behavioral health professional refers a patient for testing, Carelon will reimburse the provider for the initial psychological testing when the primary diagnosis is a carved-out behavioral health diagnosis in COMAR 10.67.08.02. If the initial testing confirms a non-carved-out diagnosis, the patients’ managed care organization will handle all future testing related to that diagnosis.
A managed care organization reimburses psychological testing related to non-carved-out behavioral health diagnoses when a preauthorization for a medical procedure requires psychological testing before the procedure. This includes testing prior to bariatric surgery, a cochlear implant, or deep brain stimulation. For more information on which codes are covered, see PT 27-24 Clarification on Payment Responsibility for Psychological Testing for Medical and Behavioral Health Services.
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| BH FAQ | How can a Medicaid provider appeal a behavioral health service claim denial? | It depends on whether you billed the service through a managed care organization or fee-for-service. Appealing a Managed Care Behavioral Health Service Denial - A HealthChoice managed care provider must appeal a primary behavioral health claim directly with the managed care organization who denied the claim.
- Follow the MCO provider appeals process or contact the MCO’s Provider Services for help with the next steps.
- If unable to resolve the matter with the MCO, contact HealthChoice Provider Network Management at [email protected] for help. Include claim examples and appeal resolution letters, if applicable.
Appealing a Fee-For-Service Behavioral Health Service Denial Appealing a Pharmacy Denial - A provider may appeal a claim denial directly with the Maryland Department of Health. For more information, see File an Appeal.
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| Accordion Name : Financial Statements (1)
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| Financial Statements | MCO Audited Financial Statements | HealthChoice Consolidated Financial Monitoring Reports
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| Accordion Name : HC Manuals (1)
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| HC Manuals | HC Manuals and Notices Templates | Member Manual TemplatesProvider Manual Templates2025 Enrollee Model Notice Templates
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| Accordion Name : HealthChoice (11)
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| HealthChoice | What is a Managed Care Organization (MCO)? | - An MCO is a healthcare organization that provides services to Medicaid recipients by contracting with a network of licensed/certified healthcare providers.
- All MCOs are responsible to provide or arrange for a wide array of healthcare services. The services and the MCOs responsibilities are described in the HealthChoice MCO Provider Agreement.
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| HealthChoice | Call the HealthChoice Help Line at 1-800-284-4510, if you | - Have questions about HealthChoice benefits.
- Have problems getting services from your MCO.
- Have questions about services that are not covered by the MCO but may be covered by Medicaid.
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| HealthChoice | How will beneficiaries know if they must enroll in an MCO and choose a Primary Care Provider? | For those who enroll in Medicaid through Maryland Health Connection:
- Log into your account www.marylandhealthconnection.gov; or
- Download Maryland Health Connection’s free mobile app, or
- Call Maryland Health Connection at 1-855-642-8572
Those that go through the Department of Human Services (DHS) for their Medicaid eligibility: - Call Maryland Health Connection at 1-855-642-8572; or
- Complete the form you received in your enrollment toolkit and mail in.
If you do not choose an MCO, the State will automatically assign you to an MCO. | 4 |
| HealthChoice | Who is not eligible to enroll in an MCO? | Medicaid beneficiaries are not eligible for HealthChoice if they:
- Are on Medicare.
- Are 65 years or older.
- Are only eligible for Medicaid under spend down.
- Are in program with limited benefits such as the Maryland Family Planning Program.
- Are in an intermediate care facility for mentally retarded persons (ICF-MR).
- Are in Model Waiver Program.
- Are already in a long term care facility or are expected to need more than 90 days of stay.
- Have been in an institution for mental disease (IMD) for 30 days.
- Are eligible for the Rare and Expensive Case Management (REM) Program and have elected to enroll in REM.
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| HealthChoice | What services are provided under the HealthChoice program? | All HealthChoice MCOs must cover basic health care benefits such as:
- Visits to the doctor, including regular check-ups
- Healthy Kids check-ups including immunizations
- Prescription drugs (No pharmacy copays for children under 21 & pregnant women)
- X-ray and lab services
- Urgent care center services
- Emergency services (also covered out of state)
- Hospital services
- Well women care
- Prenatal and postpartum care
- Family planning and birth control (No pharmacy copays)
- Home health services
- Vision exam & glasses for children under 21
- Hearing Aids
- Dental care - See the Maryland Healthy Smiles Dental Program or call 1-855-934-9812.
- HIV/AIDS drugs
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| HealthChoice | What other services do MCOs provide? | Other services related to the patient’s healthcare such as: - Outreach and home visits for certain special needs and hard-to-reach populations.
- Case management for special populations.
- Disease Management for chronic conditions.
- Assistance with coordinating transportation through the local health departments and limited transportation assistance to medical appointments.
- Health care providers are required to provide language interpretation.
- Most MCOs offer limited over the counter drugs.
For more information see the MCO Comparison Chart.
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| HealthChoice | Are long term care services provided? | If a Health Choice beneficiary requires more days in a long term care facility than is covered by the MCO, (currently 90 days or less) they must apply for Medicaid long term care (LTC) benefits. LTC eligibility requirements are more restrictive than HealthChoice. For more information see, Medicaid Long Term Services & Supports (LTSS). | 8 |
| HealthChoice | What are the additional HealthChoice benefits that are covered by Medicaid and that are not covered by MCOs? | - Behavioral health services:
- specialty mental health services like counselors, psychologists, psychiatrists
- substance use disorder treatment and recovery services
- For more information, see Optum
- Outpatient physical therapy, speech therapy, occupational therapy services for children under 21
- Personal care services – Medical day care services for adults or children
- Special support services for individuals with developmental disabilities under the Developmental Disabilities (DD) Waiver
- Health related services and targeted case management services provided to children under the child’s Individualized Education Plan (IEP) or Individualized Family Service Plan(IFSP)
- Viral load testing services, genotypic, phenotypic, or other HIV/AIDS drug resistance testing
- Non- emergency medical transportation services may be available through the local health department
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