Overview of Utilization Management

Utilization Management (UM) is one way that Maryland Physicians Care (MPC) monitors the medical necessity and cost-effectiveness of the services our members receive. Participating and non-participating health professionals, hospitals, and other providers must comply with MPC’s prior authorization (PA) and concurrent review (CCR) policies and procedures. Non-compliance with these policies may result in a delay or denial of reimbursement.

PA determination timeframes are mandated by the Maryland Department of Health. If all the necessary clinical information is received with the request, decisions are made within 2 business days and no more than 14 calendar days when additional information is required. All PA requests must be submitted on the MPC Prior Authorization Form, which is located at https://www.marylandphysicianscare.com/providers/provider-forms/.

Notifications of admissions to acute care facilities must be received within 1 business day of the inpatient admission. The CCR function provides a way to evaluate admissions while a member is hospitalized or in an inpatient facility. Admissions are reviewed for medical necessity, and continuing services are evaluated for the appropriate and timely use of inpatient medical resources. Services subject to CCR include but are not limited to those provided in acute and specialty hospitals, rehabilitation facilities, and skilled nursing facilities, including inpatient hospice care.

Admissions to post-acute facilities require an approved prior authorization. Requests for post-acute care should be faxed to our Post-Discharge fax line using the Post-Acute request form located on our website at https://www.marylandphysicianscare.com/providers/provider-forms/.

To ensure a timely response to your UM request or notifications, submit all clinical information required with your request and fax it to the applicable number below:

• PA for scheduled Inpatient, Outpatient, and Transplant Services: 800-953-8856
• Inpatient Admission Notifications: 800-385-4169
• CCR Clinical Information: 855-905-5939
• Post Discharge Service Requests: 855-905-5936

UM staff is available at least 8 hours daily during normal business hours (8 am – 5 pm EST) for inbound collect or toll-free calls. Staff can also receive inbound calls about UM after normal business hours by following the prompts and leaving a message for Prior Authorization or Concurrent Review. For CCR concerns or questions after normal business hours, providers can leave a message on the staff’s confidential voicemail. Providers can also fax requests to the appropriate fax number.

All phone communications received after normal business hours, including weekends and holidays, will be responded to on the next business day. Calls after midnight Monday-Friday will be responded to on the same business day.

Staff identify themselves by name, title, and organization when receiving and returning calls.

Language assistance is available free of charge by calling 800-953-8854. MPC provides members TDD/TTY (Telecommunication Device for Deaf/Teletypewriter) services if needed at 800-735-2258.

MPC Pharmacy: Utilization Management (UM) – Request for Information (RFI) Update

The MPC Pharmacy Team will implement a new update in Q4 of 2025 to support the prior authorization (PA) process for pharmacy benefit medications. The UM Pharmacy Team will roll out this process for electronic PA (ePA) submissions that will facilitate communication between the MPC Pharmacy Team and the requesting provider. This process will enable the Pharmacy Team to send requests for information directly to the requesting provider’s ePA vendor dashboard with a summary of the required clinical support for MPC to complete open PA requests. As we get closer to go-live, further communications will be sent to our provider network to highlight this process update for ePA submissions.

In the interim, please continue to submit completed criteria and recent supporting clinical documentation for ALL PA requests. Failure to supply required documents will delay the PA review process and could result in a denial. PA requests can be submitted via the ePA process or via fax (1-833-896-0656) using our template forms found here on our website.

MPRA Update

The Maryland Department of Health (MDH) has shared an update to the Maryland Prenatal Risk Assessment (MPRA) through Transmittal PT 68-25 requiring providers to advise patients that their information may be shared directly with their local health department (LHD) to connect them with services. It reads as follows:

Prior to administering the assessment, please read the following statement to the patient: “Information from this assessment may be shared with your local health department to help connect you to services.”

This change is expected to increase LHD efficiency, facilitate enrolling patients in more programs, and save patients from being asked duplicative, sensitive questions.

COMAR 10.67.04.08 requires that the MPRA tool be completed for all Medicaid participants at the first prenatal care visit. This regulation also requires that the MCO’s contracted prenatal care providers will, within 10 days of completing the MPRA, forward the MPRA to the LHD in the jurisdiction in which the pregnant individual lives.

Updating ePREP

Be sure not to miss reimbursement of services rendered because your electronic Provider Revalidation and Enrollment Portal (ePREP) enrollment is suspended. Providers without active enrollment or out-of-date information may not be paid for services to Maryland Medicaid recipients. Maryland Medicaid’s ePREP is a one-stop shop for provider enrollment, re-enrollment, revalidation, information updates, and demographic changes. Your information must be consistently kept up to date. The ePREP Call Center phone number is (844) 463-7768 and is available from 9 am – 5 pm ET, Monday – Friday. You may also enroll or update your information through the ePREP portal found at https://eprep.health.maryland.gov/sso/login.do.

All Medicaid providers must revalidate with Maryland Medicaid at least every five years. To revalidate ePREP, Maryland Medicaid will send a notice in the mail to prompt providers to enter ePREP and submit a specific revalidation application.

If your ePREP is suspended and then retroactively activated, please promptly resubmit claims that were denied for ePREP suspension using frequency code 1. You may also reach out to your Provider Relations Representative for additional information.