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Maryland HealthChoiceProviderQuick ReferencePrecertification/notification requirementsImportant phone numbersnRevenue codeshttps://providers.amerigroup.com/ MDPEC-2103-201
Easy access to precertification/notification requirements andother important informationFor more information about requirements, benefits and services, visit our provider self-service website to getthe most recent full version of our provider manual. If you have questions about this Quick Reference Card(QRC) or recommendations to improve it, call your local Provider Relations representative. We want to hearfrom you and improve our service so you can focus on serving your patients!Precertification/notification instructions and definitionsRequest precertifications and give us notifications: Online: https://providers.amerigroup.com/MD By phone: 1-800-454-3730 By fax: Inpatient: 1-877-855-7559 Outpatient: 1-866-920-6180For emergency or urgent services, give usnotifications within 24 hours or the nextbusiness day. There is no review against medical necessitycriteria; however, member eligibility andprovider status (network and non-network)are verified. Precertification — the act of authorizing specificservices or activities before they are rendered oroccurFor code-specific requirements for all services, visithttps://providers.amerigroup.com/MD and selectPrecertification Lookup from our Quick Tools menu.Notification — telephonic, fax or electroniccommunication received from a provider to informus of your intent to render covered medical servicesto a member: Give us notification prior to rendering servicesoutlined in this document.Requirements listed are for network providers.In many cases, out-of-network providers may berequired to request precertification for serviceswhen network providers do not.2
Audiology ServicesChiropractic ServicesAudiology services that are medically necessarywill be covered by Amerigroup Community Care forboth adults and children. For individuals under theage of 21, bilateral hearing amplification devicesare covered by the managed care organization(MCO). For adults 21 and older, unilateralhearing amplification devices are covered bythe MCO. Bilateral hearing amplification devicesare only covered for adults 21 and older incertain circumstances when the individual has adocumented history of using bilateral hearing aidsbefore age 21. These circumstances are listed in theMaryland Department of Health Audiology criteria.The state’s audiology medical necessity criteria canbe found on the Maryland Department of Healthwebsite at formation.aspx. Behavioral Health/Substance AbuseDermatology ServicesMental health and substance abuse benefitsare managed by Optum.* For questions aboutbenefits or precertification, contact Optumdirectly at 1-800-888-1965. Coordination of physical and behavioral healthcare is essential. Precertification is required.Spinal manipulation is covered under servicesrelated to early and periodic screening,diagnostic testing and treatment for membersunder age 21. Spinal manipulation is not acovered benefit for members age 21 and older.Dental ServicesMembers may self-refer for these services.One dental exam and cleaning every six monthsare covered. Also covered are limited X-rays anda 20% discount on noncovered services providedby participating dentists. Members should contact DentaQuest* at1-800-720-5949 for a listing of participatingdentists or for additional information. No precertification is required for networkproviders for evaluation and management(E&M), testing, and most procedures. Services considered cosmetic in nature orrelated to previous cosmetic procedures are notcovered. See the Diagnostic Testing section of this QRC.Cardiac RehabilitationDiagnostic TestingPrecertification is required for all services.No precertification is required for routinediagnostic testing provided in a freestandingradiology facility or physician’s office or for testsperformed in conjunction with an inpatient stay. Precertification through AIM SpecialtyHealth * is required for coverage of CTA,MRA, MRI, CAT scan, nuclear cardiology,stress echocardiography, transesophagealechocardiography, echocardiogram and PETscan. Contact AIM by phone at 1-800-714-0040or online at https://aimspecialtyhealth.com/goweb. AIM will locate a preferred imagingfacility from the Amerigroup network ofradiology service providers. ChemotherapyPrecertification is required for inpatientchemotherapy services. No precertification is required for chemotherapyprocedures when performed in outpatientsettings by a participating facility, provideroffice, outpatient hospital or ambulatory surgerycenter. For information on coverage of and precertificationrequirements for chemotherapy drugs, see thePharmacy section of this QRC.3
Diagnostic Testing (cont.)Amerigroup and providers must agree onHealthcare Common Procedural Coding System(HCPCS) and/or other codes for billing coveredservices. All custom wheelchair precertifications require amedical director’s review. All DME billed with an RR modifier (rental)requires precertification. Most outpatient diagnostic radiology servicesin the following areas of Maryland must beprecertified when provided at a hospital: AnneArundel, Baltimore, Calvert, Carroll, Charles,Harford, Howard, Montgomery and PrinceGeorge’s counties and Baltimore City. Please callAmerigroup for precertification. Outpatient radiology services excluded fromthe hospital precertification requirement(which may be provided at a hospital withoutprecertification) include radiation oncologyservices, services provided in association withan emergency room visit, services providedin association with hospital observation, andservices associated with and on the same day asan outpatient surgery performed at a hospital. For guidelines relating to disposable medicalsupplies, see the Medical Supplies section of thisQRC.Early and Periodic Screening,Diagnosis, and Treatment (EPSDT) Visit Durable Medical Equipment (DME)No precertification is required by networkproviders for glucometers and nebulizers,dialysis and end-stage renal disease equipment,gradient pressure aid, infant photo/light therapy,UV light therapy, sphygmomanometers, walkers,orthotics for arch support, heels, lifts, shoeinserts, and wedges. Precertification is required for certainprosthetics, orthotics and DME. Refer to ouronline Precertification Lookup Tool at https://providers.amerigroup.com/Pages/PLUTO.aspx. Precertification may be requested by completinga Certificate of Medical Necessity (CMN) —available at our website https://providers.amerigroup.com/pages/home.aspx — or bysubmitting a physician order and an AmerigroupReferral and Authorization Request form withappropriate clinical information. A properlycompleted and physician-signed CMN mustaccompany each claim for a service thatrequires precertification.Members may self-refer for these services.Use EPSDT schedule and documentvisits/encounters on a Centers for Medicare &Medicaid Services (CMS) 1500 (08-05) claimform. Educational Consultation No notification or precertification is required.Coverage of diabetic nutrition counseling islimited to one initial one-on-one session and upto four subsequent sessions annually.Emergency ServicesEmergency care in the emergency room doesnot require prior notification. If emergency care results in admission,notification to Amerigroup is required within24 hours or the next business day. For observation precertification requirements, seethe Observation section of this QRC.4
ENT Services (Otolaryngology)Gynecology No precertification is required for networkproviders for E&M, testing and most procedures. Precertification is required for tonsillectomyand/or adenoidectomy for members age 12and older, as well as for nasal/sinus surgery andcochlear implant surgery and services. See the Diagnostic Testing section of this QRC.Hearing AidsMembers may self-refer for these services.No precertification is required for E&M, testingand procedures if performed by an in-networkprovider. Precertification is required for elective surgeries.As of July 1, 2018, audiology services for the EPSDTpopulation will be provided through the member’sMCO. These services were placed back into theMCO system of payment. Effective July 1, 2018,audiology services are a covered Medicaid benefitfor all Medicaid participants when determined tobe medically necessary. The participant may haveto receive a preauthorization or referral from theMCO before visiting an audiologist for evaluationand/or treatment. Maryland Medical Assistance FFSrequires preauthorization on certain services.Family Planning/STD CareMembers may self-refer for these services.See the benefits limitations in your providermanual.Gastroenterology ServicesNo precertification is required for networkproviders for E&M, testing and most procedures. Precertification is required for upper endoscopyand bariatric surgery, including insertion,removal and/or replacement of adjustablegastric restrictive devices and subcutaneous portcomponents. Most outpatient gastrointestinal endoscopiesin the following areas of Maryland must beprecertified when provided at a hospital: AnneArundel, Baltimore, Baltimore City, Calvert,Carroll, Charles, Harford, Howard, Montgomeryand Prince George’s counties. Please callAmerigroup for precertification. Outpatient gastrointestinal endoscopiesexcluded from the hospital precertificationrequirement (which may be provided at ahospital without precertification) includeservices provided in association with anemergency room visit, services provided inassociation with hospital observation, andservices associated with and on the same day asan outpatient surgery performed at a hospital. Hearing ScreeningPrecertification may be required by networkproviders for diagnostic and screening tests,hearing aid evaluations or counseling. Audiology services are a covered Medicaidbenefit for all Medicaid participants whendetermined to be medically necessary. Home Health CarePrecertification is required for procedures andservices.Hospice CarePrecertification is required for inpatient hospiceservices. Notification is required for outpatienthospice services. See the Diagnostic Testing section of this QRC.5
Hospital Admission Elective admissions require precertification.Emergency admissions require notificationwithin 24 hours or next business day. For preadmission lab testing, see yourreferral directory for a complete listing ofparticipating vendors. Notify Amerigroup if same-day admission isrequired after an outpatient surgery. You can contact the health plan directly andask to speak to the Newborn Coordinator at1-410-981-4000.Detained Newborns — Hospitals should notifyAmerigroup within 24 hours or by the next businessday for transfer of a newborn from the nurseryto the NICU or to another level of care or todetain a newborn beyond the OB global period.These circumstances are considered separate,new admissions and are not part of the mother’sadmission.Laboratory Services (Outpatient)All laboratory services furnished by non-networkproviders require precertification by Amerigroupexcept for hospital laboratory services providedfor an emergency medical condition. For offices with limited or no office laboratoryfacilities, lab tests may be referred to one ofour preferred lab vendors. See your referraldirectory for a complete listing of participatinglab vendors. Observation (Obstetrical and Medical)No precertification or notification is required forin-network observation. If observation occurs inthe ER and the principal diagnosis is not on theauto-pay list, the medical record may be requestedfor review. If observation results in admission,notification to Amerigroup is required within 24hours or the next business day.Medical SuppliesObstetrical (OB) CareNo precertification is required for most disposablemedical supplies. Please check our PrecertificationTool at https://providers.amerigroup.com/Pages/PLUTO.aspx. NeurologyNo precertification is required for networkproviders for E&M and testing. Precertification is required for neurosurgery,spinal fusion and artificial intervertebral discsurgery. See Diagnostic Testing. Newborn Care We will designate a newborn coordinator (NC)to serve as a point of contact for providerswho have questions or concerns related to theeligibility of services for newborns during thefirst 60 days after birth. No precertification is required for obstetricalvisits or OB diagnostic testing and laboratoryservices when performed by a participatingOB provider’s office, freestanding lab orfreestanding radiology center.Notification of pregnancy and delivery toAmerigroup at 1-800-964-3627 is required at thefirst prenatal visit and following birth.Per routine pregnancy, one ultrasound iscovered. Additional ultrasounds are coveredbased on medical necessity and current practicestandards. Please refer to the Ultrasound Policylocated at o precertification is required for labor,delivery and circumcision for newborns upto 12 weeks in age. However, notification ofdelivery is required within 24 hours, along withnewborn information.OB case management programs are available.See the Diagnostic Testing section of this QRC.6
Ophthalmology (Outpatient)PharmacyPrecertification is required for hospitals in thefollowing counties: Anne Arundel, Baltimore,Carroll, Harford, Howard, Montgomery andPrince George’s. Precertification is not requiredfor hospitals in Baltimore City. Please callAmerigroup for precertification. In all other Maryland counties, precertification isnot required. Services provided in association with anemergency room visit, detached retina cases andservices that always require general anesthesiaare excluded from precertification. Services considered cosmetic in nature are notcovered. The pharmacy benefit covers medicallynecessary prescriptions and over-the-counter(OTC) medications prescribed by a licensedprovider. The benefit is provided under a closedformulary/Preferred Drug List (PDL); exceptionsand restrictions apply. Refer to our online PDL for preferred productswithin therapeutic categories and requirementsaround generics, step therapy, quantity edits,and the prior authorization process. Submit a prior authorization request by calling1-800-454-3730 or using our Pharmacy OnlineMedication Precertification Tool that allowsyou to: Submit requests for general pharmacy —medications dispensed directly to a memberfrom retail pharmacy or shipped from aspecialty pharmacy. Request medical injectables for thosemedications obtained by your office/facilityfor onsite infusion or administration. Check precertification status. Appeal denied requests. Upload supporting documents and reviewappeal status.Log in at https://providers.amerigroup.com/MD. Go to Tools Precertification Request. Youmust be a registered user to access the tool. Oursite also offers tutorials to guide you throughthe medication prior authorization process andother helpful functions. Providers can submit a prior authorization viafax 1-866-452-5017 or online throughthe CoverMyMeds* website athttps://www.covermymeds.com/main. See the Diagnostic Testing section of this QRC.Oral MaxillofacialSee the Plastic/Cosmetic/Reconstructive Surgerysection of this QRC.Out-of-Area/Out-of-Network CarePrecertification is required except for emergencycare (including self-referral) and OB delivery.Outpatient/Ambulatory SurgeryPrecertification requirement is based on theservices being performed.Pain Management/Physiatry/PhysicalMedicine and RehabilitationNon-E&M-level testing and procedures requireprecertification for coverage.7
Pharmacy (cont.)Radiation TherapyMost self-injectable medications, selfadministered oral specialty medications andmany office-administered specialty medicationsare available through IngenioRx SpecialtyPharmacy* and require prior authorization (PA).To initiate a PA request, call 1-833-255-0646.Call IngenioRx at 1-833-203-1742 or fax to1-800-378-0323 to schedule delivery once youreceive a PA approval. For a complete list ofdrugs available through IngenioRx Specialty,visit the Pharmacy section of our provider selfservice site, https://fm.formularynavigator.com/FBO/4/Maryland PDL English.pdf. Many injectable drugs and their counterpartsin the same therapeutic class requireprior authorization by Amerigroup whenadministered from a provider’s supply. Use thePrecertification Lookup tool on our website tofind prior authorization requirements by code.No precertification is required for radiation therapyprocedures when performed in the followingoutpatient settings by a participating facility:provider office, outpatient hospital or ambulatorysurgery center. RadiologySee the Diagnostic Testing section of this QRC.Rehabilitation Therapy (Short-Term):occupational therapy (OT), physicaltherapy (PT), radiation therapy (RT) andspeech therapy (ST)Rehabilitation therapy services are a coveredAmerigroup benefit for members youngerthan age 21 only if part of a home health visitor inpatient hospital stay. Precertificationis required for services beyond the initialassessment. Rehabilitation therapy services that are not partof a home health visit or inpatient hospital stayare provided under Maryland’s MedicaidFee-For-Service program for children youngerthan age 21. Rehabilitation therapy services are a coveredbenefit for members age 21 and older. Precertification is required for PT and OTservices beyond the initial assessment for adultsage 21 and older. OrthoNet, LLC* conductsmedical necessity reviews for adult PT and OTservices. Medical necessity criteria must be met.Request precertification by calling OrthoNet* at1-855-596-7618 or faxing clinical information to1-855-596-7626. Plastic/Cosmetic/ReconstructiveSurgery (including Oral MaxillofacialServices)No precertification is required for oralmaxillofacial E&M services. All other services require precertification,including treatment of trauma to the teeth andoral maxillofacial medical and surgical conditionssuch as TMJ. Services considered cosmetic in nature orrelated to previous cosmetic procedures are notcovered. Reduction mammoplasty requires amedical director’s review. See the Diagnostic Testing section of this QRC.PodiatrySkilled Nursing FacilityNo precertification is required for E&M, testing andmost procedures when provided by a participatingpodiatrist.Precertification is required.8
Sleep StudyUrologyPrecertification is required. Precertification is required for hospitals in thefollowing counties: Anne Arundel, Baltimore,Baltimore City, Carroll, Harford, Howard,Montgomery and Prince George’s. In all other Maryland counties, precertification isnot required. Services provided in association with anemergency room visit and services that alwaysrequire general anesthesia are excludedfrom precertification.SterilizationSterilization services are a covered benefit formembers age 21 and older. No precertification or notification is required forsterilization procedures, including tubal ligationand vasectomy. A Sterilization Consent form is required forclaims submission. Reversal of sterilization is not a covered benefit. Vision Care (Routine)Members may self-refer for services and shouldcall Superior Vision* at 1-844-585-2020 for moreinformation.Termination of PregnancyWe are not responsible for coverage of abortionprocedures, related services provided at a hospitalon the day of the procedure or during an inpatientstay, or an abortion package as may be provided ata freestanding clinic; however, we are responsiblefor coverage of any related services not indicatedabove that may be performed as part of a medicalevaluation prior to the actual performance ofan abortion. Additionally, we are responsible forreferring members who require or express a needfor an abortion to a Medicaid-participating serviceprovider.Well-woman ExamMembers may self-refer for services. See thebenefit limitations in the provider manual.TransportationRevenue (RV) CodesMembers can contact their local health departmentfor assistance, or we can contact the departmenton behalf of the member. The local healthdepartments are posted on the state website —visit www.dhmh.maryland.gov and click on theLDHS tab.To the extent the following services are coveredbenefits, precertification or notification isrequired for all services billed with the followingrevenue codes:All inpatient and behavioralhealth accommodations 0023 — Home health prospectivepayment system 0632 — Pharmacy multiple source Urgent Care CenterNo notification or precertification is required forparticipating facilities.9
Important Contact InformationProvider Experience ProgramOur Provider Services team offers precertification,case and disease management, automated membereligibility, claims status, health education materials,outreach services, and more. Call1-800-454-3730, Monday through Friday from8 a.m. to 6 p.m. Eastern time.Provider Self-service Site and IVR Available24/7/365:To verify eligibility, check claims and referralauthorization status, and look up precertification/notification requirements, visit https://providers.amerigroup.com/MD. You may also visit theAvaility* Portal for: Eligibility and benefit inquiries Claim status inquiries Claim submissions A direct link to the Amerigroup provider selfservice website for all other functionality,including panel listings, precertification requestsand appeals; you can access the link locatedunder the My Payer Portal in the left-handnavigation bar on the Availity website.Our Service PartnersDentaQuest(dental services formembers age 21 and older)Providers call1-800-341-8478Superior Vision(vision services)1-844-585-2020Who should I call if I have questions about theAvaility Portal?Contact Availity Client Services at 1-800-Availity(1-800-282-4548) or email questions tosupport@availity.com. Availity Web Portal ClientServices is available Monday through Friday from5 a.m. to 4 p.m. Pacific time (excluding holidays).Healthy Smiles Providers callDental Program1-844-275-8753(dental services for members Members callyounger than age 21 and1-855-934-9812pregnant women)IngenioRx SpecialtyPharmacy(for specialty drugs)AIM Specialty Health(radiology precertification)Can’t access the Internet?Call Provider Services and simply say your NationalProvider ID when prompted by the recorded voice. Therecording guides you through our menu of options —just select the information or materials you need whenyou hear it.Phone:1-833-255-0646 Fax:1-833-263-2871 1-800-714-004010
Claims ServicesWhen submitting an appeal on behalf of a member,write a letter or use the Provider Appeals form on ourwebsite. You MUST have written authorization from themember to act as the designated representative.Timely filing is within 180 calendar days of the date ofservice.Electronic Data Interchange (EDI)Health ServicesCall our EDI hotline at 1-800-590-5745 to get started.We accept claims through three clearinghouses: Care Management Services 1-800-454-3730We offer care management services to members whoare likely to have extensive health care needs. Our nursecare managers work with you to develop individualizedcare plans, including identifying community resources,providing health education, monitoring compliance,assisting with transportation, etc.Emdeon (payer 27514)Capario (payer 28804)Availity (payer 26375)Paper ClaimsDisease Management (DM) Services 1-888-830-4300Submit claims on original claim forms (CMS 1500 orCMS 1450) printed with dropout red ink or typed(not handwritten) in large, dark font. AMA- and CMSapproved modifiers must be used appropriately basedon the type of service and procedure code. Mail to:Amerigroup Community CareClaimsP.O. Box 61010Virginia Beach, VA 23466-1010DM services includes addressing the health needs of ourmembers through education and connecting membersto local community support agencies and events in thehealth plan’s service area as applicable. DM servicesare available for members with the following medicalconditions: asthma, bipolar disorder, COPD, CHF, CAD,diabetes, HIV/AIDS, hypertension, obesity, majordepressive disorder for adults and adolescents andschizophrenia.Payment DisputesNurse HelpLine 1-800-600-4441 (TTY 711)Claims payment disputes, or grievances, must be filedwithin 90 business days of the adjudication date of theexplanation of payment. Forms for provider appeals areavailable on our website. Mail to:Amerigroup Community CarePayment Dispute UnitP.O. Box 61599Virginia Beach, VA 23466-1599Members can call our 24-hour Nurse HelpLine for healthadvice 7 days a week, 365 days a year. When a memberuses this service, a report is faxed to your office within24 hours of receipt of the call.Member Services 1-800-600-4441(TTY 1-800-855-2880)* IngenioRx, Inc. is an independent company providingpharmacy benefit management services on behalf ofAmerigroup Community Care. Availity is an independentcompany that administers the secure provider portal on behalfof Amerigroup Community Care. AIM Specialty Health is aseparate company providing utilization review services onbehalf of Amerigroup Community Care. Optum is a separatecompany providing behavioral health/substance abuse serviceson behalf of Amerigroup Community Care. DentaQuest isa separate company providing dental services on behalf ofAmerigroup Community Care. Superior Vision is a separatecompany providing vision services on behalf of AmerigroupCommunity Care. OrthoNet, LLC is an independent companyproviding musculoskeletal management services on behalfof Amerigroup Community Care. CoverMyMeds is a separatecompany providing prior authorization review services onbehalf of Amerigroup Community Care.Medical AppealsMedical appeals, or medical administrative reviews,can be initiated by members or providers on behalf ofmembers and must be submitted within 90 businessdays from receipt of an adverse determination. Submitappeals in writing to:Amerigroup Community CareCentralized Appeals ProcessingP.O. Box 61599Virginia Beach, VA 23466-242911
6 Hospital Admission n Elective admissions require precertification. n Emergency admissions require notification within 24 hours or next business day. n For preadmission lab testing, see your referral directory for a complete listing of participating vendors. n Notify Amerigroup if sa
