MedicaidPrior AuthHigh impact
HealthChoice Carve-In for Cinryze® and Spinraza®
Maryland Medicaid·MD · Pharmacy, Pediatrics, Neurology +1 more·Provider Transmittal
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
Effective January 1, 2021, HealthChoice MCOs (managed care) assume responsibility for preauthorization, processing, and payment of Cinryze® and Spinraza®. Fee-for-Service (FFS) claims continue through Maryland Department of Health. Providers must route MCO claims to the participant's respective MCO and FFS claims through established MDH channels with updated preauthorization forms.
Action Required
By December 31, 2020: Billing team must immediately update internal workflows to distinguish between HealthChoice MCO participants and FFS participants for Cinryze® and Spinraza® claims. For MCO participants: contact the member's specific MCO for preauthorization and billing requirements (do not send to MDH). For FFS participants: continue submitting preauthorization requests to MDH using either the Preauthorization Request Form - Physician Administered Injectable Drugs (Professional Services Program) or the High Cost Drug Preauthorization form/Spinraza Preauthorization form (Pharmacy Program). Update billing software and claim routing rules to reflect this split-path process. Train all billing and authorization staff on the new routing requirements. Establish contact protocols: Pharmacy Program questions → 1-800-492-5231 option 3; Professional Services questions → kimberly.stevenson@maryland.gov; MCO-related questions → pam.williams@maryland.gov. Failure to route claims correctly will result in denials and payment delays.