MedicaidReimbursementMedium impact
PT 38-26: Billing Practices of Individual Consideration Priced Items
Maryland Medicaid·MD · PM&R (Physical Medicine & Rehab), Physical Therapy, Occupational Therapy·Claims & Billing
Effective date
Nov 24, 2025
We identified it
Jun 18, 2026
Summary
Maryland Medicaid has issued new guidance on billing durable medical equipment (DME) and disposable medical supplies (DMS) without Medicare-established rates using Individual Consideration pricing methodology. Providers must submit MSRP pricing for prior authorization, then can optionally submit wholesale invoices for potentially better reimbursement rates based on specific percentage calculations.
Action Required
Immediately: DME/DMS providers must update billing workflows to submit MSRP pricing with all Individual Consideration prior authorization requests to Telligen. After equipment purchase, fax wholesale invoices with DME/DMS Corrections Form to 888-297-4276 to request wholesale cost reimbursement. Update billing staff training on the two-step reimbursement methodology and percentage calculations for different item types.