MedicaidPrior AuthHigh impact
Self-Referral Services Available for HealthChoice Members
Maryland Medicaid·MD · OB-GYN, Family Medicine, General Practice +4 more·Managed Care Organizations
Effective date
Feb 4, 2025
We identified it
Jun 20, 2026
Summary
Maryland Medicaid HealthChoice MCOs must now cover specific self-referral services without prior PCP authorization at Medicaid FFS rates when provided by out-of-network Medicaid-enrolled providers (except emergency services). This policy supersedes PT 70-24 and clarifies that emergency service providers do NOT need Medicaid enrollment. All self-referred services must use in-network pharmacy and laboratory services.
Action Required
IMMEDIATELY: (1) Billing team must update MCO claim submission workflows to recognize self-referral services for family planning, pregnancy-related, EPSDT initial screening, SBHC (including sports physicals), emergency services, HIV/AIDS diagnostics, renal dialysis (Medicare-certified facilities only), and COVID-19 lab tests as non-requiring prior authorization. (2) For family planning claims, ensure ICD-10 diagnosis codes from Z30 series are included on all claim forms so MCOs recognize preventive medicine/E&M codes as family planning services. (3) Verify provider Medicaid enrollment status before submitting claims for all self-referral services EXCEPT emergency services (no enrollment required for emergency providers). (4) Implement 6-month billing deadline tracking from date of service for all self-referral claims. (5) Update encounter forms and provider education materials to identify self-referral services and confirm in-network pharmacy/lab use. (6) Reference PT 66-24 for modifier 32 billing on initial health screening visits for children in state-supervised care. (7) Obtain current COVID-19 fee schedules from https://mmcp.health.maryland.gov/Pages/Provider-Information.aspx for accurate reimbursement codes. Failure to follow self-referral protocols will result in claim denials; incorrect pharmacy/lab routing will delay reimbursement.