MedicaidAdministrativeMedium impact
MWPH: Procedures for Retrospective Review to Determine Medical Necessity of Services Provided
Maryland Medicaid·MD · Pediatrics·Hospital
Effective date
Oct 28, 2024
We identified it
Jun 20, 2026
Summary
Mount Washington Pediatric Hospital now has two options when the utilization control agent denies a continued stay review: pursue a full retrospective review for the entire rate or bill for medically necessary ancillary services on denied days. The hospital must choose between these options and cannot pursue both.
Action Required
Immediately: MWPH billing team must establish workflow to handle CSR denials by choosing between Option 1 (full retrospective review with required documentation submitted through Qualitrac portal within 90 days) or Option 2 (billing medically necessary ancillary services using form 1288). Train staff on the two payment rates for respiratory vs non-respiratory ancillary services per Provider Transmittal 12-25.