MedicaidCoverageMedium impact
Clarification on HealthChoice Coverage for Special Pediatric Hospitals
Maryland Medicaid·MD · Pediatrics, Critical Care·Provider Transmittal
Effective date
Mar 29, 2024
We identified it
Jun 20, 2026
Summary
This policy clarifies MCO (HealthChoice) coverage responsibilities for enrollees in Special Pediatric Hospitals. MCOs cover the first 90 days of stay; on day 91, the state's utilization control agent reviews medical necessity. If disenrollment to fee-for-service is denied and the child remains enrolled, the MCO must continue coverage for all medically necessary care including ancillary services on inpatient hospital days.
Action Required
By April 15, 2024: Billing team must update internal workflows and claims processing guidelines to reflect MCO coverage responsibility extension beyond 90 days when disenrollment denial is issued by the state utilization control agent. Coordinate with HealthChoice MCO contacts to confirm notification of disenrollment denials at the 91-day mark. Ensure claims for ancillary services (lab, imaging, therapy) provided on inpatient hospital days after day 90 are submitted to the MCO rather than fee-for-service Medicaid. Train billing staff to recognize disenrollment denial notices and adjust claim routing accordingly. Failure to submit claims to the correct payer will result in claim denials and payment delays.