MedicaidPrior AuthMedium impact
Hepatitis C Virus (HCV) Retrospective Review Process, effective January 1, 2021
Maryland Medicaid·MD · Infectious Disease, Gastroenterology, Internal Medicine·Provider Transmittal
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
Effective January 1, 2021, Maryland MCOs now have direct authority to approve prior authorization requests for Hepatitis C (HCV) medications without Department pre-approval. The Maryland Department of Health will conduct monthly retrospective reviews to ensure MCOs comply 100% with HCV Clinical Criteria, with sanctions imposed for non-compliance.
Action Required
By January 1, 2021: Billing and prior authorization teams must verify that the practice's MCO has received and implemented this transmittal. For HCV medication requests: (1) Submit prior authorization requests directly to the MCO rather than the Maryland Department of Health; (2) Ensure MCO approvals reference compliance with HCV Clinical Criteria (Attachment A); (3) Document all HCV therapy prior authorizations submitted to MCOs for compliance tracking, as the Department will retrospectively audit MCO decisions monthly. Alert providers that prior auth processing timelines may change under direct MCO review. Failure to comply with MCO-approved HCV Clinical Criteria may result in claim denials and departmental sanctions against the MCO.