MedicaidAdministrativeMedium impact
Changes to Emergency Service Review Submission Procedures for Undocumented or Unqualified Aliens (X02/X03)
Maryland Medicaid·MD · Emergency Medicine, Nephrology·Provider Transmittal
Effective date
Nov 1, 2020
We identified it
Jun 20, 2026
Summary
Effective November 1, 2020, Maryland Medicaid changed the emergency service review submission process for undocumented or unqualified aliens. Providers must now complete sections 1-2 of the OES 401 form at time of service/discharge, with applicants submitting it to local DSS/LHD offices. Upon eligibility approval, providers must submit the completed OES 401 plus medical records to Telligen within 60 days via myqualitrac.com (or email for dialysis providers). Eligibility applications must be filed within 6 months of service date.
Action Required
By November 1, 2020: (1) Billing and clinical teams must obtain and implement the revised OES 401 form for undocumented or unqualified aliens receiving emergency or dialysis services. (2) Providers must complete sections 1 and 2 of the OES 401 and distribute to patients at time of service or discharge. (3) Establish internal process to track when DSS/LHD returns completed OES 401 (sections 3-4 completed). (4) Billing team must submit completed OES 401 plus relevant medical records to Telligen via https://myqualitrac.com within 60 days of financial eligibility approval (dialysis providers submit to X02@telligen.com). (5) Ensure eligibility applications are submitted within 6 months of service/discharge date. (6) Train front desk, clinical, and billing staff on new process. Failure to follow submission timelines will result in claim denials and inability to obtain reimbursement for emergency services rendered to this population.