Maryland Medical Assistance: Prior Authorization
Contents
- What is prior authorization?
- When is prior authorization required?
- How to request prior authorization?
- How is the decision made?
- What if the decision is not in my favor?
- How long does the process take?
- What are the most common reasons for denial?
- How can I appeal the decision?
- What are some tips for a successful prior authorization request?
- Conclusion
If you’re a Maryland resident and you need medical assistance you’ll need to get prior authorization from the state. Here’s what you need to know about the process.
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In general, prior authorization is the process of getting approval from Maryland Medical Assistance (MMA) before you receive a service or fill a prescription. Prior authorization may be required for certain services, treatments, drugs, durable medical equipment (DME), and supplies.
To get prior authorization for a service, you or your provider must contact MMA’s HealthChoice program to request approval. The HealthChoice program will review the request and determine whether the service is covered and whether prior authorization is required.
If prior authorization is required, MMA will notify you or your provider of the decision. If your request for prior authorization is approved, you will be able to receive the covered service. If your request is denied, you will be responsible for paying for the service.
Prior authorization is required for certain services, including but not limited to:
-Inpatient hospitalizations
-Certain outpatient hospital procedures
-Certain surgeries
-Certain Durable medical equipment (DME)
-Certain home health services
-Certain prescription drugs
You may request prior authorization for medical services by contacting your provider.
How is the decision made?
A Medical Assistance provider must submit a written request for prior authorization to the local Department of Health and Mental Hygiene (DHMH) office that serves the county in which the patient resides. Middle andoult;requests can be faxed to the utilization management vendor. The request must include:
-The medical necessity for the services or supplies
-The patient’s name, date of birth, gender, Medicaid ID number and contact information
-The name, address, telephone number and National Provider Identification (NPI) number of the requesting provider
-The dates of service
-A detailed description of the services or supplies requested, including brand name(s), if applicable
-Any available documentation to support the request
Requests will be reviewed by licensed clinical staff. The staff will review all pertinent information to make a determination based on medical necessity. The decision will be made within 5 business days from receipt of all necessary information.
What if the decision is not in my favor?
If you don’t agree with the decision, you have the right to file an appeal.
How long does the process take?
The process of obtaining prior authorization from Maryland Medical Assistance can take some time. First, you will need to submit a request for authorization, which can be done online or by fax. Once your request has been received, a determination will be made as to whether or not you meet the eligibility guidelines. If you are found to be eligible, you will be asked to provide additional information, such as a treatment plan or medical records This process can take several weeks.
What are the most common reasons for denial?
There are a few reasons why Maryland Medical Assistance (MMA) may deny prior authorization for a procedure or medication. The most common reasons are:
-The procedure or medication is not medically necessary
-The procedure or medication is experimental or investigational
-There is a less expensive alternative that would be just as effective
-The patient does not meet the eligibility criteria for the program
How can I appeal the decision?
If you disagree with the decision, you can ask for a hearing. This is called an “appeal.” You have the right to appeal any decision made about your case, including:
-eligibility
-the amount of your co-payment
-the type or amount of services you will receive
-disability determinations
To appeal a decision, you must request a hearing within 60 days from the date on the notice telling you about the decision.
Some tips for a successful prior authorization request include:
– Providing all required documentation, including the Maryland Medical Assistance plan member’s primary care provider’s certification, to the health care provider or facility requesting the service;
– Ensuring that the health care provider or facility requesting the service is enrolled in Maryland Medical Assistance and accepts Maryland Medical Assistance patients;
– Calling Provider Services at 1-800-999-1118 to verify receipt of the request and to obtain the fax number or mailing address of the plan if the request is incomplete; and
– Following up with Provider Services at 1-800-999-1118 if you have not received a response to your request within 10 business days.
Conclusion
In conclusion, the Maryland Medical Assistance: Prior Authorization process is an important step in ensuring that patients receive the care that they need. It is a complex process, but one that is essential to ensuring that patients receive the best possible care.
