Maryland providers face a continuous stream of payer policy changes: coverage edits, prior authorization expansions, billing code revisions, and Medicaid reimbursement updates that affect day-to-day practice operations. This page surfaces every tracked policy change that explicitly names Maryland, so your billing and compliance teams can act before the effective date, not after a claim denial.
Maryland Medicaid has extended the HCBS Cost Survey submission deadline from September 30, 2026, to December 31, 2026. All Medicaid-enrolled HCBS providers who billed for services between July 1, 2025, and June 30, 2026, must submit complete financial and operational data by the new deadline or face payment suspension starting January 1, 2027.
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
Maryland Medicaid is transitioning to NCPDP Telecommunication Standard Version F6 for pharmacy transactions, with a phased implementation beginning August 14, 2027 (concurrent with Version D.0) and mandatory exclusive use by April 14, 2028. For 340B drug program claims, the identifier code is changing from Submission Clarification Code 20 (field 420-DK) to Submission Type Code AA (field D17-K8). Billing teams must update systems, coordinate with vendors, and prepare for impacts across claims processing, eligibility, and rebate reporting.
Effective January 1, 2027, CareFirst BlueCross BlueShield is updating prior authorization requirements for durable medical equipment and advanced diagnostic imaging services for CareFirst CHPMD members in Maryland. The source indicates these changes clarify when prior authorization is required but does not specify which services are newly required, newly exempt, or changing in scope. Additionally, CareFirst CHPMD providers can now submit medication prior authorizations electronically through the provider portal starting November 2, 2026.
Maryland Medicaid will reimburse eligible providers for Family and Medical Leave Insurance (FAMLI) employer contributions beginning January 1, 2027, when employers start withholding contributions from employee paychecks. Reimbursement covers actual costs capped at the state-set employer contribution rate (0.45% for 2027) for nursing homes, medical day care, private duty nursing, personal care, HCBS, Community First Choice, developmental disability services, and behavioral health services. Providers must submit documentation to MDH by December 11, 2026, to confirm eligibility and reimbursable amounts.
Maryland MCOs must transition their Care Coordination Module (CCM) reporting for the MOM benefit from the CRISP system to in-house MCO systems, effective January 1, 2027. MCOs will produce all MOM reporting directly from their systems and submit monthly extracts to MDH by the 15th of the following month, with system testing required by October 1, 2026.
Maryland Medicaid is reinstating the HealthChoice Social Determinants of Health Workgroup to develop a standardized, non-proprietary HRSN (Health-Related Social Needs) screening questionnaire to replace current proprietary instruments. This transition aims to reduce administrative burden, improve cost efficiency, and ensure consistent data collection across all HealthChoice MCOs. The new screening tool is targeted for implementation on January 1, 2027.
CareFirst BlueCross BlueShield is notifying providers of upcoming Medicaid changes effective January 1, 2027, requiring Maryland Medicaid members to meet new federal work and renewal requirements to maintain coverage. Providers should begin educating patients now using CareFirst-provided toolkit materials to help members avoid coverage gaps and stay informed of changes.
Maryland Medicaid MCOs must transition their MOM (Maternity Obstetrical and Medical) benefit Care Coordination Module reporting from CRISP system to in-house systems by January 1, 2027. MCOs will submit monthly data extracts to MDH instead of entering data into CRISP.
Maryland Medicaid is ending retrospective authorization approvals for Health Home services effective November 1, 2026. Providers must now submit complete intake information and receive authorization approval from BHASO before delivering any services. This is a significant shift from the temporary retrospective approval process that was previously allowed for continuity of care.
Maryland Medicaid launched the MPRIME provider enrollment system on October 13, 2026, replacing ePREP. All providers must create new user accounts and associate themselves with existing provider profiles; previous ePREP logins do not transfer. Providers without valid SDAT identification numbers in good standing will be suspended effective October 13, 2026. Facilities and organizations must submit updated licenses or certifications through MPRIME by March 31, 2027, or face automatic suspension on April 1, 2027.
Maryland's Home and Community-Based Options Waiver is transitioning assisted living provider billing from eMedicaid to the LTSSMaryland data management system effective October 1, 2026. Providers must establish portal accounts, verify provider locations, and assign staff roles (Admin Provider or Billing Provider) by the deadline to avoid billing disruption. The new system will automate eligibility verification and exception flagging, with a Thursday-Wednesday billing week and payments via direct deposit by the following Friday.
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
This is a comprehensive Medicare Advantage bariatric surgery coverage policy (HUM-1020-005) effective October 1, 2026, that outlines coverage determinations, limitations, and coding requirements for various bariatric procedures. The policy applies Humana's Medicare Advantage coverage standards and references applicable MAC Local Coverage Determinations by geographic jurisdiction, with specific rules varying by state and MAC region.
Maryland Medicaid is transitioning from the ePREP provider enrollment system to a new system called MPRIME. All providers must download any needed documents from ePREP by September 30, 2026, at 5pm, as access will be completely disabled on October 1, 2026. MPRIME will launch on October 13, 2026, and providers can set up accounts anytime on or after that date.
Maryland Medicaid is transitioning its provider enrollment system from ePREP to MPRIME in October 2026. Providers must submit pending applications and complete revalidations before temporary hold periods (July 1 for moderate/high-risk providers, August 1 for limited-risk providers), then create new MPRIME accounts and re-associate with existing records when the system goes live. Failure to act could result in enrollment suspension and inability to contract with MCOs.
This is a revised Medicare Advantage medical coverage policy for spinal fusion surgery (effective 09/01/2026) that consolidates coverage determination, limitations, coding information, and evidence summaries for cervical, lumbar, and thoracic spinal fusion procedures. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) across geographic jurisdictions and outlines covered procedures including traditional fusion, minimally invasive approaches (DLIF, XLIF, MITLIF), sacroiliac joint fusion, and interlaminar fusion techniques. Billing teams must align claims submission with the applicable MAC LCD based on patient location and ensure procedures meet specific medical necessity criteria outlined in the referenced determinations.
CareFirst CHPMD is implementing three major updates: (1) Maryland Medicaid transitioning from ePREP to MPRIME portal effective October 13, 2026, requiring providers to re-register and update enrollment information; (2) New electronic medication prior authorization submission process via CareFirst Provider Portal (CareFirst Direct) effective September 1, 2026, replacing manual submission; and (3) New federal work and renewal requirements for Maryland Medicaid members effective January 1, 2027, requiring members to verify eligibility to maintain coverage.
This is a comprehensive Medicare Advantage coverage policy for Benign Prostatic Hyperplasia treatments effective September 1, 2026. The policy outlines coverage determinations for multiple BPH treatment modalities including surgical procedures (TURP, prostatectomy, laser therapies), temporary implanted devices, stents, and diagnostic testing. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) that vary by geographic jurisdiction, requiring billing teams to verify applicable coverage rules based on patient location.
Humana Medicare Advantage has revised its Ambulatory Cardiac Monitoring Devices policy effective September 1, 2026. The policy provides updated coverage guidance for various cardiac monitoring technologies (Holter monitors, patch recorders, external loop monitors, implantable loop recorders, and mobile cardiac outpatient telemetry) with MAC-specific coverage determinations by geographic jurisdiction. The policy document appears incomplete but establishes that medical necessity determinations will follow applicable NCDs and LCDs based on the member's jurisdiction.
Maryland Medicaid is changing its Return to Provider (RTP) application process effective September 1, 2026. Starting that date, deficient provider enrollment applications will be denied instead of returned for correction. Any applications currently in RTP status must be corrected by 5:00 PM on August 31, 2026, or they will be denied and providers must reapply through the new MPRIME system launching in October 2026.
Maryland's Department of Health has issued updated compliance audit procedures for Residential Service Agencies (RSAs) providing Personal Assistance/Care Services under Community First Choice and related waiver programs. The policy establishes a formal progressive enforcement framework including desk reviews, site visits, Plans of Correction with 15-day response requirements, and escalating sanctions (suspension, payment withholding, termination) for non-compliance. Providers who fail to respond to audit initiation will be suspended after three outreach attempts.
This is a comprehensive Medicare Advantage coverage policy for neuroablative techniques used to treat chronic pain, effective 08/06/2026. The policy defines coverage criteria, eligible procedures (including radiofrequency ablation, cryoablation, chemical neurolysis, and specialized devices like Intracept), and references MAC-specific LCDs and billing codes by geographic jurisdiction. Billing teams must verify applicable MAC guidelines for their state and ensure claims comply with local coverage determinations.
This is a comprehensive Medicare Advantage policy on neuroablative techniques for chronic pain management, effective 08/06/2026. The policy defines covered denervation procedures (radiofrequency ablation, cryoablation, facet denervation, basivertebral nerve ablation, and others) and references MAC-specific LCDs and NCDs that vary by geographic jurisdiction. Billing teams must verify applicable MAC requirements for their region before processing claims for these procedures.
This is a comprehensive Medicare Advantage policy on genetic testing for hereditary cancer syndromes, effective August 3, 2026. The policy establishes coverage guidelines for germline genetic testing across multiple cancer types (melanoma, gastric cancer, neuroendocrine tumors, renal cell carcinoma, and others) and references specific MAC-based Local Coverage Determinations (LCDs) that vary by geographic jurisdiction. Billing teams must verify applicable MAC jurisdiction and LCD requirements before processing claims.
Humana Medicare Advantage has revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
Humana Medicare Advantage has updated its Breast Excision and Mastectomy policy (HUM-1254-009) effective 08/03/2026. This revised policy clarifies coverage criteria for breast lesion excisions (CPT 19120, 19125), partial mastectomies (CPT 19301, 19302), and gynecomastia mastectomy (CPT 19300) across multiple MAC jurisdictions. The policy establishes specific medical necessity criteria based on biopsy results, lesion characteristics, and anatomical considerations, and applies jurisdiction-specific Local Coverage Determinations (LCDs) for Medicare Administrative Contractors.
This is a comprehensive Medicare Advantage policy for Benign Prostatic Hyperplasia (BPH) treatments that became effective on August 3, 2026. The policy outlines coverage for multiple surgical and minimally invasive treatment modalities including TURP, laser therapies, temporary implanted devices, and stents, with specific coverage determinations varying by MAC jurisdiction. Billing teams must verify applicable MAC-specific LCDs and NCDs by geographic location before processing BPH treatment claims.
Maryland Medicaid is conducting annual encounter data validation audits from August through November 2026, comparing medical records against claims submissions. Billing providers must ensure documentation is complete, accurate, and properly aligned with billed procedure, diagnosis, and revenue codes to avoid audit findings, claim denials, or payment recoupments.
Maryland HealthChoice MCOs and PBMs must allow enrollees to fill specialty drug prescriptions at any capable retail pharmacy, rather than restricting them to mail order pharmacies. This policy prohibits steering practices that limit enrollees' pharmacy choice for specialty drugs and requires MCOs to ensure retail pharmacies can provide required education and management support.
The Maryland Department of Health has issued a notice of payment delays affecting all Medicaid providers in Maryland. Payments scheduled for July 9-10, 2026 (both direct deposits and checks) will be delayed, with resolution expected by mid-week of the following week. The underlying technical issue has been resolved.
Maryland Medicaid updated eligibility criteria for 1915(i) Intensive Behavioral Health Services and Targeted Case Management (TCM) Level 3 for children ages 0-21, expanding enrollment eligibility and relaxing intensity thresholds. Additionally, Child and Family Team (CFT) meeting frequency was extended from every 30 days to every 60 days, and audio-only telehealth reimbursement was eliminated for five expressive/experiential behavioral services (art, dance, horticulture, music, and drama), which now require audio-visual telehealth with GT modifier.
Maryland Medicaid requires Behavioral Technicians (BTs) upgrading to Registered Behavior Technicians (RBTs) to submit a NEW enrollment application under provider type RB with RBT certification by July 31, 2026, before the August 1 MPRIME system hold. Current BT provider IDs will be terminated upon approval of the new RBT account. Providers missing the deadline cannot upgrade until October 2026.
Maryland's nursing home quality assessment rates increase 3.54% for FY 2027, from the FY 2026 baseline to $34.11 per non-Medicare patient day (except five high-Medicaid facilities at $2.80). Nursing facilities must report resident days via the Cognito form and remit payments by source-stated quarterly deadlines or face late fees and potential collection action. This policy establishes reporting and payment requirements effective for FY 2027 quarters.
Maryland Medicaid is transitioning from the ePREP provider enrollment portal to a new Medicaid Provider Enrollment portal launching in October 2026. Effective July 1, 2026, high and moderate risk provider types cannot submit new enrollments, revalidations, or account changes through ePREP. Effective August 1, 2026, limited risk provider types face the same restriction. Providers must wait until the new portal goes live to make any enrollment updates.
Effective July 1, 2026, Maryland Medicaid requires ABA providers to submit the National Provider Identifier (NPI) of the referring practitioner on all claims and verify that the referring provider is actively enrolled as a Medicaid provider on the date of service. Claims without a valid, active individual referring provider NPI will be denied.
Maryland Medicaid is implementing a mandatory Home and Community-Based Services (HCBS) Cost Survey effective July 1, 2026. All HCBS providers who billed Medicaid from July 1, 2025–June 30, 2026 must complete and submit the survey by September 30, 2026, reporting cost, utilization, workforce data, and the percentage of payments spent on direct care worker compensation. This data will inform future rate-setting methodology and assess payment adequacy.
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.
Maryland Medicaid Developmental Disabilities Administration is reducing Targeted Case Management (TCM) service rates by 2% effective July 1, 2026. Comprehensive Assessment rate drops to $441.00 per assessment, and TCM coordination services decrease to $27.76 per 15-minute unit statewide, with a higher geographic differential rate of $29.76 per 15-minute unit for five designated Maryland counties (Calvert, Charles, Frederick, Montgomery, Prince George's).
Maryland Medicaid nursing facility rates are increasing by 1% effective July 1, 2026, based on FY 2027 budget bill SB0282. Rates are adjusted by each facility's case mix index and include 2024 rebasing data. The Medicare coinsurance worksheet has been updated, and the personal needs allowance increases to $109.00 per month per Medicaid participant.
Maryland Medicaid is transitioning from ePREP to MPRIME enrollment system in October 2026, with application holds starting July 1st for high/moderate risk providers and August 1st for limited risk providers. Providers must submit applications before holds begin or wait until MPRIME launches, with potential backdated enrollments available through December 31, 2026.
Maryland Medicaid clarifies that nursing facilities must bill administrative days using Form 2129 starting on the first day of a continued stay review (CSR) period when a patient lacks a valid level of care determination. Facilities may continue full Medicaid billing only if an appeal is filed within 10 days of a denied level of care notification. Any claims already paid at full rate during denied periods must be corrected through the claims adjustment process.
Maryland Medicaid has established a claim resubmission opportunity for doula services rendered between May 1, 2024 and May 1, 2026, allowing providers to correct previously underbilled claims by requesting void of initial claims and resubmitting with accurate 4-unit billing for 60-minute visits. The policy also clarifies the 8:1 reimbursement model, fee schedule effective July 1, 2023, and eligible place-of-service codes for prenatal (T1032), postpartum (T1032 U9), and labor/delivery (T1033) services.
Maryland Medicaid providers are prohibited from balance billing members for any reason, including when charges exceed fee schedules, claims are denied, or during claim reviews. Providers must verify eligibility before services and can only collect permitted cost-sharing amounts.
Maryland Medicaid updated administrative days reimbursement requirements for nursing facilities. Facilities must document at least three placement attempts per month with no more than two-week intervals, submit the MDH 2129 form within 15 calendar days after the claim month ends, and use only revenue code 0169 for billing. This policy supersedes PT 27-06 and PT 25-11, with stricter documentation requirements and potential payment recoupment for non-compliance.
Effective April 1, 2026, Maryland Medicaid is eliminating 100% telehealth delivery for three specific ABA services (CPT 97155, 97156/97156-U2, and 97157). Providers must now deliver at least 25% of these services in-person, with up to 75% via telehealth. All telehealth claims must be billed with the GT modifier. This supersedes prior telehealth guidance in PT 11-22.
Maryland Medicaid updated billing requirements for Community Violence Prevention (CVP) services effective April 1, 2026. CVP providers must now maintain a contractual affiliation with a trauma hospital (documented via letter in ePREP), bill initial encounters with specific place-of-service codes (19, 21, or 22), use CPT 99402 for all CVP services, and apply telehealth modifiers (GT for visual-audio, UB for audio-only) when applicable.
Starting April 1, 2026, ABA telehealth services for supervision and parent training must include at least 25% in-person delivery, with only 75% allowed via telehealth. Providers must use GT modifier when billing for telehealth portions of these services.
Maryland Medicaid has implemented a new process to address 'zero checks' - missing payments to providers due to data discrepancies between Medicaid and the Comptroller's office. Provider accounts with zero checks will be suspended until data issues are resolved, and providers will be contacted to verify information and submit updated W-9 forms.
Maryland Medical Assistance Program updates FY 2026 case management rates for Medical Day Care Services, effective March 16, 2026. The reimbursement rate for MDC case management services is set at $23.2645 per 15-minute unit using procedure code S5103. The policy clarifies 13 billable activities and 12 non-billable activities, with a minimum 8-minute duration threshold for all billable services.
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