MAPS-MD Issues Bulletin

April 2001

MAPS-MD has received four new membership groups from the State of Maryland. Each group is eligible through Medicaid for Pharmacy Coverage only. Because these members meet Gray Zone financial eligibility requirements, they will automatically receive gray zone membership spans. Eligibility for these consumers will be reflected on the gray zone web site (www.gzmd.com). Authorizations for these membership groups will follow the same rules and those for gray zone members.

For a document with details and questions regarding the above, see the MAPS-MD web site, MAPS-MD.com. The document is listed under "New."

Misuse of Emergency Call Line

Recently some providers have attempted to use MAPS-MD’s emergency phone line for non-emergencies. Please note that use of the emergency line for non-emergencies may cause dangerous delays for consumers who are truly in crisis and/or at risk of harming themselves or others.

Attachments to Claims

Please note that the only attachments to paper claims submitted to MAPS-MD should be documents required by the state for payment such as EOBs, DJJ orders of commitment for RTC claims, etc. Providers must not attach additional information such as charts, medical records, or progress notes when submitting a claim for processing to the MAPS-MD Claims Department.

Billing Training Sessions for providers set for May and June

Please see attached invitation / registration sheet for times. Pre-registration is required.

HCFA 1500 (non-hospital based providers) training (Day 1):

UB92 (hospital based providers) training (Day 2):

Guidelines when MAPS-MD is the Secondary Payer

Consumers with Other Insurance

When consumers in the PMHS have other insurance, either commercial or Medicare, Maryland Health Partners is considered the secondary (or in some cases, the tertiary) carrier. There are some circumstances where MAPS-MD will become the primary carrier:

1. Benefits are exhausted under the other carriers.
2. The services are not covered under the primary carrier.
3. The member is not eligible through the primary insurance carrier on the date of service.

In all of the above cases, pre-authorization of treatment MUST be obtained from Maryland Health Partners for all services that require pre-authorization.

There are instances where the primary carrier denies the services and MAPS-MD will NOT become the primary carrier. These include, but are not limited to:

1. Pre-authorization of services was not obtained from the primary carrier.
2. Claim for service was improperly billed.
3. Claim was not submitted timely.
4. Failure of consumer, provider or other responsible party to comply with policies and procedures set forth by the primary carrier(s).
5. Private insurance denies the service as "not medically necessary".

In the cases above, MAPS-MD will not pay for the services even if pre-authorization has been given because the primary carrier is still responsible under these circumstances. The provider is expected to complete the primary carrier's full appeals process.

Pre-authorization Requirements for the PMHS

As indicated within the MAPS-MD Provider Manual, all services, with the exception of emergency services, must have pre-authorization and subsequent care must be pre-authorized prior to the service being delivered. Soon, MAPS-MD will begin strictly enforcing this policy. On rare occasions, outpatient types of service authorization can be backdated for one month. If a pattern is noted that a particular provider is regularly requesting backdated authorizations, this may trigger MAPS-MD to conduct an audit.