MedicaidAdministrativeHigh impact
Clarification of Payment Responsibility of Emergency Medical Professional Fees in Emergency Department Settings
Maryland Medicaid·MD · Emergency Medicine, Psychiatry·Provider Transmittal
Effective date
Nov 8, 2021
We identified it
Jun 20, 2026
Summary
This policy clarifies that emergency medicine professional fees in emergency department settings are the responsibility of HealthChoice MCOs (not the behavioral health carve-out organization), regardless of the patient's diagnosis. Even when a patient has a mental health diagnosis, emergency department services billed by emergency medicine providers must be submitted to the MCO, not the BHASO. Only services rendered by specialty mental health providers are the BHASO's responsibility.
Action Required
Effective immediately: (1) Billing team must verify that all emergency medicine professional fee claims from ED encounters are routed to HealthChoice MCOs, NOT to the behavioral health administrative services organization (BHASO), regardless of the patient's primary diagnosis. (2) Update billing system logic to ensure mental health diagnoses do not trigger automatic routing to BHASO for ED emergency medicine provider services. (3) Providers must ensure emergency medicine clinician fees are billed with appropriate emergency service modifiers/codes consistent with EMTALA requirements and 10.67.05.08F definitions. (4) Training staff must understand the distinction: only specialty mental health providers (as defined in COMAR 10.09.59.04) billing from the ED should be routed to BHASO. Failure to properly route claims may result in denials and delayed reimbursement. Contact mdh.healthchoiceprovider@maryland.gov for MCO billing questions.