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Updated Prior Authorization Process for Special Pediatric Hospitals
Effective date
Jul 1, 2026
Identified
Jul 17, 2026
Summary
Maryland Medicaid reinstates prior authorization requirements for special pediatric hospital transfers, effective July 1, 2026. This reverses the January 2026 removal of prior auth requirements. Providers must now submit prospective reviews before admission OR concurrent reviews within 5 calendar days of admission, with continued stay reviews required every 3 days. Failure to use correct timing in Qualitrac will result in case closure and claim denials.
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What to do
Action · 18 steps
01REQUIREMENTS:
By June 30, 2026: Billing and clinical teams must immediately update all workflows for special pediatric hospital admissions.
02This is a REVERSAL of PT 48-26 (prior auth removal effective Jan 1, 2026).
031. UPDATE BILLING SYSTEM: Configure billing software to require prior authorization for ALL special pediatric hospital admissions (in-state and out-of-state) submitted to Telligen beginning July 1, 2026.
042. ESTABLISH PROSPECTIVE REVIEW PROCESS: Train transferring providers and admissions staff to submit prospective reviews to Telligen BEFORE admission when possible.
05Instruct them to select "prospective" timing in Qualitrac.
063. ESTABLISH CONCURRENT REVIEW PROCESS: If prior auth is NOT obtained before admission, the special pediatric hospital MUST submit the first concurrent review to Telligen within 5 calendar days of the requested start date.
07Instruct hospital staff to select "concurrent" timing in Qualitrac.
084. CONFIGURE CONTINUED STAY REVIEWS: Program system to require continued stay reviews within 3 days of current level of care expiration date (before or after).
09All subsequent reviews must use "continued stay review" timing in Qualitrac.
105. RESUBMISSION PROTOCOL: Train billing team that if Telligen closes a case with "outcome not rendered" due to incorrect timing selection, the review must be immediately resubmitted with correct timing.
11This will delay payment processing.
126. PAYMENT IMPACT DOCUMENTATION: Ensure billing team understands: If concurrent or prospective review determines the patient did NOT meet special pediatric hospital level of care, the hospital will NOT receive the full per diem rate.
13Administrative days are NOT available for the requested start date if patient doesn't qualify.
14Administrative days only apply if patient initially qualifies but later no longer meets criteria.
157. CONTACT INFORMATION: For Medicaid Fee-for-Service questions, direct to Jarrod Terry (jarrod.terry@maryland.gov).
16For HealthChoice MCO questions, contact mdh.healthchoiceprovider@maryland.gov.
17CONSEQUENCES: Claims submitted without proper prior authorization using correct Qualitrac timing will be denied or closed without payment determination.
18Incorrect per diem reimbursement will occur if level of care is not properly documented and approved.
Original notice
Updated Prior Authorization Process for Special Pediatric Hospitals
health.maryland.gov · Always check the source before changing claims.
Related changes
See all Maryland Medicaid changes →Removal of Prior Authorization Requirement for Special Pediatric HospitalsHighEffective Jan 1, 2026 · Managed Care OrganizationsNew Review Process for Special Pediatric Hospitals, Effective October 7, 2026MediumEffective Oct 7, 2026 · Special Pediatric HospitalPT 48-26: Removal of Prior Authorization Requirement for Special Pediatric HospitalsMediumEffective Jan 1, 2026 · Prior AuthorizationBrowse every Maryland Medicaid change in the policy list