Navigating the complexities of prior authorizations can be a time-consuming task for healthcare providers. At Maryland Physicians Care (MPC), we understand the need for efficiency and clarity. That’s why we offer a user-friendly Maryland Physicians Care Auth Lookup Tool designed to simplify and expedite the pre-authorization process.
This powerful tool allows you to quickly determine if a service requires prior authorization, ensuring you have the necessary approvals in place before rendering care. Using the MPC Pre-Authorization tool can significantly reduce claim denials and streamline your administrative workflow.
Quickly Check Authorization Requirements
Our MPC Pre-Authorization tool is designed for speed and ease of use. Simply enter the service code you wish to check, and the tool will instantly provide you with the authorization requirements. This immediate feedback allows you to:
- Verify authorization needs instantly: Know upfront whether a service requires pre-authorization.
- Save time and resources: Avoid lengthy phone calls and manual lookups.
- Reduce claim denials: Ensure you have proper authorization before service delivery.
- Improve workflow efficiency: Streamline your pre-authorization process.
[Use the MPC Pre-Authorization Tool Now] (Link to tool if available, otherwise remove link text and keep sentence)
If prior authorization is indeed required, you can conveniently submit your request online through our provider portal, further simplifying the process. Submit Authorization Online.
Important Prior Authorization Guidelines
While the online tool is regularly updated for accuracy, it’s crucial to be aware of specific service categories that consistently require prior authorization. Please note these key situations, and if you can’t find a specific code in the tool, don’t hesitate to contact Clinical Review at (800) 953–8854, options 2 then 4 for assistance.
Services That Typically Require Pre-Authorization:
- Elective Hospital Admissions (Non-Emergency): All planned, non-emergency hospital admissions necessitate prior authorization.
- Oncology and Radiation Oncology Services: Pre-authorization is mandatory for all oncology and radiation oncology services. An Eviti Code is required before submitting your authorization request. For access to our oncology and radiation oncology services vendor, please visit www.eviti.com. For Maryland Physicians Care, Eviti now handles biomarker test authorization requests. Utilize the checklist under Provider forms and fax to 888-468-1423 to begin the Eviti review.
- Rehabilitative and Habilitative Therapy Services: After the initial evaluation, prior authorization is needed for rehabilitative and habilitative therapy services, including those provided by Chiropractors. Authorization is not required for services in a hospital emergency department, observation unit, inpatient unit, acute rehabilitation hospital, or skilled nursing facility. Contact Evolent at www.RadMD.com or (800) 424-4836 before or within 5 business days of service delivery.
- Non-Emergent Outpatient Cardiac Procedures: Certain cardiac procedures, including CT/CTA, MRI/MRA, PET Scan, CCTA, Myocardial Perfusion Imaging, MUGA Scan, Stress Echocardiography, and Echocardiography (TTE/TEE), require pre-authorization when performed on an outpatient basis and are non-emergent. Cardiologists can obtain authorizations through Evolent at www.RadMD.com or (800) 424-4836. Approved authorizations are valid for 60 days from the request date.
- High-Tech Radiology and Non-Emergent Musculoskeletal Procedures: This category includes outpatient, interventional spine pain management services, and MSK surgeries managed by Evolent (list available here). Obtain authorizations via Evolent at www.RadMD.com or (800) 424-4836.
- Place of Service for Laboratory and Radiology: Maryland Physicians Care mandates that laboratory and radiology services be performed at free-standing (non-regulated) facilities. Services in hospital/facility (regulated) spaces will require authorization. Some radiology and laboratory services may need pre-authorization regardless of the service location.
- Infusion Medications: Certain medications for infusion must be administered in free-standing (non-regulated) infusion facilities or via home infusion. Infusion services for these medications in hospital/facility (regulated) settings will require authorization. Most medications under the medical benefit require pre-authorization regardless of where they are administered.
- Outpatient Procedures in Ambulatory Surgical Centers (ASCs): Maryland Physicians Care requires defined CMS outpatient procedures to be performed in an Ambulatory Surgical Center (ASC). Services in a hospital/facility (regulated) space will require authorization. Certain procedures require pre-authorization regardless of location. Use the code checker tool for specific requirements.
- Outpatient Hospital or Facility-Based Surgical Services: These services may require prior authorization. Always verify using the Pre-Auth Check tool.
- Durable Medical Equipment, Homecare, Therapy, and Hospice: Prior authorization is necessary for durable medical equipment, homecare, therapy, and hospice services. Utilize the Pre-Auth Check tool to determine specific procedure requirements.
- Non-Participating Providers: Non-participating providers must obtain prior authorization for all services, except for emergency and self-referred services. Participating providers must obtain pre-authorization for services not exempt from requirements. Services needing pre-authorization may be denied if authorization is not secured.
Medicaid High-Cost Drug Policy
Maryland’s Department of Health has a risk mitigation policy for very high-cost drugs (annual cost over $500,000 in CY 2024; previously $400,000). This policy affects both Physician Administered Drugs and retail pharmacy drugs. View the High-Cost Drug List Here. Prior authorization is required for these high-cost drugs regardless of the place of service. Even with inpatient or outpatient service authorizations, a specific medication authorization is needed for drugs on this list before administration.
For Non-Participating Providers
If you are a non-participating provider, remember that prior authorization is needed for all services except emergent and self-referred ones. Consider becoming an MPC provider to simplify processes and better serve your patients.
Disclaimer: While we strive to keep the Pre-Auth Needed Tool current, it does not guarantee payment. Claim payment depends on eligibility, covered benefits, provider contracts, accurate coding, and billing practices. When in doubt, submit a pre-authorization request for a definitive answer.
For comprehensive details, consult our Quick Reference Guide.
