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ISSUE 3 / FALL 2026
Maryland Provider Registration and Information Management Enterprise (MPRIME) Upcoming Training Sessions
Via Medicaid Transmittals 59-26 and PT 65-26, Provider Enrollment Portal Transition, the Maryland Department of Health (MDH) announced that Maryland Medicaid will transition from ePREP, the current online provider enrollment and revalidation portal system, to Maryland Provider Registration and Information Management Enterprise (MPRIME), a new Medicaid provider enrollment portal. MPRIME is scheduled to go live in October 2026.
As stated in Medicaid Transmittal PT-04-27, Maryland Medicaid is offering training sessions to help providers learn how to navigate and operate the new system.
These training sessions will cover:
MPRIME functionality and provider registration;
Submitting a new enrollment application;
Submitting an update application; and
Navigating the re-validation process.
Providers can go to Registration: MPRIME System Training to register for training. Each
training will be hosted several times. Pre-recorded versions of the trainings will also be posted to the MPRIME webpage closer to the MPRIME launch.
Additional information, including enrollment tutorials, recorded trainings, provider resources, and the provider enrollment checklist, can be found on the MPRIME - New Provider Enrollment Portal.
For any questions regarding this transmittal, please contact mdh.mprimegolive@maryland.gov.
Language Service Support and Language Profile
MPC provides quality-certified oral interpreter services for members. This service is also available for providers who need interpretation service during healthcare encounters with our members through our language line vendor.
If you have an MPC member in your office who needs assistance with oral interpretation, please call us at 1-800-953-8854 and request interpreter services.
Also, to assist providers, MPC has developed a member Language Identification Tool. This tool can be found at the following link, https://www.marylandphysicianscare.com/wp-content/uploads/2026/06/MPC-I-Speak-Cards_FINAL.pdf.
Your MPC Provider Relations Representative can also provide you with a virtual or hard copy of the Language Identification Tool.
As a statewide Maryland Medicaid MCO, MPC completed a language profile in August 2024 that provides insight into the many languages spoken throughout our service area. You can find the language profile on our website at the bottom of the page at https://www.marylandphysicianscare.com/members/news-and-events/annual-notice-to-maryland-physicians-care-members/. MPC identified English and 42 additional languages/language groupings within the State of Maryland. In addition to English, 39 languages are considered threshold languages, spoken by 1,000 persons or 5% of the population.
New Rules for Medicaid Coming Soon
A new federal law, H.R. 1, adds new requirements for up to 320,000 Maryland Medicaid members, many of whom may be exempt from these requirements. Maryland Physicians Care is working closely with the Maryland Department of Health and Maryland Health Connection to help our members navigate these new changes and stay covered.
Stay informed by visiting the Maryland Department of Health webpage at: https://health.maryland.gov/mmcp/Pages/workrequirements.aspx
What is changing?
Starting Jan. 1, 2027, the federal government is requiring new rules for some adults to keep Medicaid coverage. These include:
- Show you are working or taking part in other activities (also called work requirements)
- Renew your Medicaid coverage twice a year
MDH and the MCOs will be contacting members that may be impacted in the Fall of 2026 in advance of changes that may occur during each recipient’s upcoming Medicaid renewal throughout 2027.
What is changing for immigrants?
Starting Oct. 1, 2026, a few non-citizen immigrants will no longer qualify for Medicaid coverage. This new law applies to adults, but not to children or pregnant people. Visit the Maryland Department of Health’s Immigration Status Requirements page for more information.
Special Needs CM Referrals
Members who need more individualized care can receive added support from the Care Management Team. Visit the HealthChoice Provider Manual on the MPC website if you need guidance on HIV Care, maternal health services, or programs for other specialized support services.
You may send a Special Needs Care Management referral three ways:
- Email: MPCSNC@mpcmedicaid.com
- Toll-Free: 800-953-8854or 443-300-7325
- Fax: 844-284-7698
It is important to include the following information in the referral:
- Member’s Name, Date of Birth, and Medicaid Number
- The reason for the referral
- A good contact number for the member
When submitting a referral, include whether the member is aware of the referral to help Care Management better support and engage with them during point of contact.
Practical Communication Tips for Healthcare Providers
Clear, respectful communication improves outcomes for both patients and providers. Evidence-based guidance from public domain sources reinforces what clinicians experience every day.
- Start with plain language. Using everyday words and avoiding jargon helps patients better understand diagnoses, risks, and next steps, particularly when stress or fear is present.
- Next, lead with the main message. Patients should be able to identify the most important takeaway within the first few moments of an interaction or written message.
- Focus on one or two actions at a time. Overloading people with information reduces recall and adherence, even when the information is accurate.
- Finally, check for understanding. Inviting patients to explain information back in their own words builds trust and uncovers confusion before it becomes a problem.
You can explore additional, freely-available tools and research through the CDC Gateway to Health Communication and the NIH Clear Communication initiative.
Increasing Perinatal Engagement
Providers are often the first point of contact for pregnant members, making early engagement an important opportunity to connect members with the support they need.
MPC offers comprehensive programs to help expectant and new mothers access services throughout the prenatal and postpartum periods. These programs include care management and care coordination support to help members navigate healthcare services and address social determinants of health. MPC also offers the free Pacify App, which connects members with Care Managers and Lactation Consultants. Providers can review the health education programs available on the MPC website here, along with the services below for prenatal and postpartum members:
- Doula Support Services: Provides emotional and physical support to members before, during, and after pregnancy and childbirth. Visits may take place in the member’s home.
- Maternal Opioid Misuse Program: Provides care management to help address gaps in care for pregnant and postpartum members with opioid use disorder (OUD). Benefits continue for one year following the end of the pregnancy.
For more information about prenatal and postpartum care, or services available in your county, please visit MPC’s Pregnancy-Related Support Services site.
Correct Coding Corner:
- If your Maryland Medicaid NPI is suspended or terminated and later reinstated, please resubmit any claims previously denied during the reinstatement period with a frequency code 1 as soon as possible; timely filing rules still apply.
- In compliance with the MDH Transmittal, PT50-26_NCCI_Reminders.pdf, MPC promotes correct claims coding including submission of documentation as required. Use of these claims edits will enable you and your billing staff to more readily understand our payment/denial of claims given the widespread use of these policies.
- Maryland HealthChoice offers doula services to support birthing parents and babies during pregnancy, labor and delivery, and postpartum. Members are eligible if they are active with MPC and are pregnant or have delivered a child within the past 180 days. Eligible members may self-refer to an ePREP-approved doula or contact MPC’s Special Needs Coordinator at MPCSNC@mpcmedicaid.com.
- Maryland Physicians Care has updated its coverage policy for Genitourinary Pathogen Nucleic Acid Amplification Testing (NAAT). This testing may be covered when medically necessary to evaluate specific symptoms or high-risk conditions.
When reporting molecular testing, providers should use the most specific CPT code available. Non-specific molecular testing codes 87797, 87798, and 87799 are not reimbursable when a more specific code exists.
Health Education Resources for Providers Like YOU
As a provider, we know you want to educate your patients on the benefits of following your recommendations, but time is limited during appointments. MPC is here to help you offer patients credible, evidence-based health education. Our Prevention & Wellness (P&W) staff can provide the time needed to educate them with that information through a variety of ways, including several online tools and resources:
- Fill out a Health Education Request Form by visiting the website or clicking on the QR code below.
- Let them know that they can fill out a member Health Education Form.
- Direct them to our Health and Wellness Library, or
- Contact the P&W staff directly at preventionandwellness@mpcmedicaid.com.
Our goal is to make access to Health Education for your patients, our members, easier to access. Patients with low health literacy are more likely to visit the ER, have more hospital stays, less likely to follow treatment plans, and have higher mortality rates.
Check out our UPDATED rack card for more information:
Why Accurate Demographic Data in Provider Directories Matters
For physicians, maintaining accurate demographic data in provider directories is more than an administrative requirement; it is a direct support to patient access, trust, and continuity of care. A wrong phone number, outdated office location, incorrect panel status, or inaccurate network listing can delay care, frustrate patients, and create unnecessary operational burden for practices.
Patients rely on directories to choose physicians, confirm whether a doctor is in network, identify locations, schedule appointments, and determine whether a practice is accepting new patients. When this information is accurate, patients are more likely to reach the right clinician at the right time. When it is inaccurate, the result may be missed appointments, inappropriate referrals, unexpected costs, and loss of confidence before the physician-patient relationship even begins.
Accurate directory data also benefits physicians and their teams. It reduces misdirected calls, scheduling confusion, claim issues, and avoidable patient complaints. It supports compliance with payer and regulatory expectations and reinforces the professionalism of the practice. Key demographic elements, such as name, specialty, office address, phone number, office hours, languages spoken, telehealth availability, hospital affiliation, network participation, and panel status, should be reviewed whenever changes occur and verified on a routine schedule. Optional data, such as race, ethnicity and language, if disclosed, will not be used for discriminatory purposes during credentialing or contracting.
To maintain accuracy, practices should assign ownership for directory updates, create a standard workflow for changes, document submissions to health plans, and educate front-desk and scheduling staff to report discrepancies quickly. Treating directory data as a shared operational responsibility helps prevent small errors from becoming barriers to care.
Ultimately, demographic accuracy is part of patient-centered care. Physicians offer expertise in the exam room, but patients first need a reliable pathway to reach that expertise.
Risk of Lead Exposure in Children
Educating parents on the risk of lead exposure in children is an important step to keeping their children safe and healthy. Lead exposure can occur in everyday activities and often has no visible signs. There are no safe levels of lead exposure for children; even low levels can affect their growth and development. Providers can help parents reduce their children's exposure by using well-child visits to discuss common lead hazards and suggest ways families can create a safer environment through their daily routines.
Parents should be aware that lead can be found in:
- Homes that were built before 1978, especially if they have paint chipping or peeling
- Older plumbing fixtures and drinking water
- Lead-contaminated dust or soil
- Some imported toys, jewelry, candies, cosmetics, and other items
- Certain occupations or hobbies that involve lead-containing products that can be brought into the home
Creating simple habits like washing hands regularly, cleaning with a wet cloth to pick up dust, using cold water for drinking, and keeping children away from peeling paint can help reduce lead exposure. Food rich in calcium, iron, and vitamin C may also help limit the body's absorption of lead.
Providers can make a meaningful impact by educating families, recommending routine lead screenings based on age and risk factors, and helping parents identify lead hazards and reduce risk in their child's everyday environment. These steps help families create a safer environment to support healthy growth and development.
For additional resources, see the lead portion of the Children’s Health page on the MPC site which includes a link to Maryland’s Lead Prevention Program. You can also explore the CDC website: Know the Facts | Childhood Lead Poisoning Prevention.
Opioid Pain Management
The management of opioid medications and access to these treatments remains a high priority for Maryland Physicians Care (MPC). MPC utilizes the requirements established in the MDH/MCO criteria. For outpatient opioid prior authorization requests, MPC requires recent clinical documentation that includes urine drug screenings, review of PDMP, opioid/pain management agreements, and the prescribing option of naloxone to complete a review.
Failure to supply required documents will delay the prior authorization review process and could result in a denial. Opioid prior authorization requests can be submitted via the electronic prior authorization (ePA) process or via fax (1-833-896-0656) using our opioid PA form found on our website here. Below are formulary preferred opioids which may also be found on the preferred drug list.
Help Your Patients Keep Their Medicaid Coverage With MPC!
Maryland Medicaid requires members to renew their coverage.
Your patients must renew their coverage with Maryland Health Connection this year to keep their health insurance benefits. Patients can renew their insurance by:
- GOING ONLINE to Maryland’s Health Connection at https://marylandhealthconnection.gov/checkin
- CALLING Maryland’s Health Connection’s Customer Service at 1-855-642-8572
- VISITING MPC’s website at mpcmedicaid.com/renew-membership
REMIND your patients to take these very important steps to keep their MPC coverage.
For more information to assist your patients, please visit the MDH website at https://health.maryland.gov/mmcp/Pages/home.aspx.
Site of Service Prior Authorization
MPC applies medical necessity criteria to determine whether an outpatient hospital site of service is medically necessary or whether the procedure can be safely and effectively performed at an alternate site of service, such as a network ambulatory surgery center.
CMS guidelines are used to help identify surgeries and procedures that may be appropriate for an ambulatory surgery center setting. For the most current CMS guidelines, visit: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.
The site-of-service prior authorization process applies to all requests for outpatient procedures in a regulated outpatient hospital setting. When making a prior authorization decision, MPC considers the member’s individual needs, the availability of services within the contracted network, the provider’s credentials to perform the procedure in an ambulatory surgery center, and the provider’s ability to meet the member’s needs. MPC also considers whether ambulatory surgery centers are available within required geographic access standards.
MPC recognizes that an ambulatory surgery center may not be an appropriate site of service for every member. For details on outpatient hospital setting medical necessity considerations, please refer to the Outpatient Surgical Procedures Policy (PA-27), available on the MPC website at Medical Management - Maryland Physicians Care. The policy can also be found through the MPC clinical policies link in the Provider Portal under the Resources tab.
If you cannot provide the service because you do not have Ambulatory Service Center privileges and the member needs assistance, MPC’s special needs coordinator is available to assist the member at MPCSNC@MPCmedicaid.com or 800-953-8854.
Breast Cancer Screening Awareness
Breast Cancer Awareness not only reminds us of the significant impact of this disease and honors the individuals and families affected by it, but it also provides an opportunity for providers to support those who have been diagnosed with breast cancer, encourage patients to stay current with recommended screenings, and provide ongoing education.
Early breast cancer often has no symptoms, making routine screenings essential. About 1 in 8 women in the United States will be diagnosed with breast cancer in their lifetime. Annual mammograms are recommended for women ages 40 to 74, based on individual risk factors and current clinical guidelines. Routine breast cancer screenings play a key role in early detection; however, some patients remain overdue or non-adherent with their mammograms.
Here are some ways to support patients and encourage them to take a step forward towards early detection:
- Create a safe space for patients to ask questions and express their concerns.
- If a patient is hesitant, especially those with a family history, take the time to talk through their concerns and help them make an informed decision.
- Offer educational materials and connect them with trusted resources, including the Women's Health section of the MPC website.
- Utilize your care team to help identify those who are overdue for screenings and proactively flag the patient.
Breast cancer screenings rates continue to decline. Provider engagement and patient-focused communication are important steps to improving screenings within all populations and early detection.
Encourage your MPC patients to view the Screening Test & Vaccines and Women's Health section of the Self-Management Tools for more information.
Utilization Management Overview
Utilization Management (UM) is one way Maryland Physicians Care (MPC) reviews the medical necessity and cost-effectiveness of services provided to members. Participating and non-participating health professionals, hospitals, and other providers must follow MPC’s prior authorization (PA) and concurrent review (CCR) policies and procedures. Failure to comply may delay or deny reimbursement.
PA decision timeframes are set by the Maryland Department of Health. MPC makes Prior Authorization decisions within 2 business days of receipt of necessary clinical information, but not later than 7 calendar days if additional information is needed. All PA requests must be submitted using the MPC Prior Authorization Form, available at https://www.marylandphysicianscare.com/providers/provider-forms/.
Admission notifications for acute care facilities must be received within 1 business day of inpatient admission. CCR supports review of admissions while a member is hospitalized or in an inpatient facility. Admissions are reviewed for medical necessity, and ongoing services are assessed for appropriate and timely use of inpatient medical resources. Services subject to CCR include, but are not limited to, care provided in acute and specialty hospitals, rehabilitation facilities, skilled nursing facilities, and inpatient hospice settings.
Admissions to post-acute facilities require approved prior authorization. Post-acute care requests should be faxed to the Post-Discharge fax line using the Post-Acute request form available at https://www.marylandphysicianscare.com/providers/provider-forms/.
For a timely response to UM requests or notifications, include all required clinical information and fax it to the appropriate 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
Medical necessity clinical criteria are available at the point of care through the provider portal with links to the InterQual criteria and medical clinical policies are linked under the resources tab.
UM staff are available at least 8 hours each day during normal business hours (8 a.m.–5 p.m. EST) for inbound collect or toll-free calls. After hours, callers may follow the prompts and leave a message for Prior Authorization or Concurrent Review. For CCR concerns or questions after hours, providers may leave a message on the staff’s confidential voicemail. Providers may also fax requests to the appropriate fax number.
Phone communications received after normal business hours, including weekends and holidays, will be returned the next business day. Calls received after midnight Monday through Friday will be returned the same business day.
Staff identify themselves by name, title, and organization when receiving and returning calls.
Free language assistance is available by calling 1-800-953-8854. MPC also provides TDD/TTY (Telecommunication Device for Deaf/Teletypewriter) services for members, if needed, at 800-735-2258.
HELP PREVENT
FRAUD, WASTE, AND ABUSE
Participating providers must report to MPC any suspected fraud, waste, abuse, inappropriate practices, or inconsistencies they identify within the Medicaid program.
Fraud and abuse occur when false information is provided to receive healthcare benefits or services. Examples include:
- Members using an ID card that belongs to someone else.
- Members under-reporting income, insurance, resources, or assets.
- Practitioners billing for services or supplies that were not provided.
- Practitioners providing unsolicited supplies to beneficiaries.
- Practitioners misrepresenting a diagnosis, a beneficiary’s identity, the service provided, or other facts to justify payment.
- Practitioners prescribing or providing excessive or unnecessary tests and services.
- Selling prescription medications or altering a written prescription.
You may report fraud and abuse without fear of reprisal. You do not need to provide your name or contact information; however, if you choose to do so, MPC will keep it confidential. Please provide as many details as possible to support a complete and thorough investigation.
Fraud and abuse may be reported in the following ways:
- CALL MPC’s Compliance Hotline at 1-866-781-6403 and leave a detailed message.
- GO ONLINE at Fraud & Abuse - Maryland Physicians Care to complete the Fraud and Abuse Form.
- WRITE to the Compliance Officer at MPC, 1201 Winterson Road, 4th Floor, Linthicum Heights, MD 21090.
Fraud and abuse are against the law. MPC reports all suspected incidents of fraud and/or abuse to the Maryland Department of Health, Office of Inspector General, for further investigation. Under the Maryland False Claims Act, administrative sanctions may include, but are not limited to, denial, suspension, or revocation of a provider application or license. Remediation may include, but is not limited to, education, sanctions, debarment, and criminal penalties.
Member Rights & Responsibilities
Members have Rights and Responsibilities that apply to their treatment, privacy, and access to information.
Member rights include, but are not limited, to the following:
- Receive healthcare and services that are culturally competent and free from discrimination.
- Be treated with respect to their dignity and privacy.
- Receive information about treatment options and alternatives, regardless of cost or benefit coverage, in a manner they can understand.
- Participate in decisions regarding their healthcare, including the right to refuse treatment.
- Request and receive a copy of their medical records and request that they be amended or corrected.
Member responsibilities include, but are not limited, to the following:
- Be on time for appointments and notify providers as soon as possible if they need to cancel or reschedule an appointment.
- Show their membership card at every appointment and never allow anyone else to use their card.
- Provide MPC and their providers with accurate health information to provide proper care.
Please read the full list of the member rights and responsibilities on Page 8 of the Provider Manual or on our website at https://www.marylandphysicianscare.com/rights-and-responsibilities.
What can I do on the MPC Provider Portal?
- Check the Status of Claims
- View your Remittance Advices
- View PCP Member panels, including member’s spoken language
- Check Member’s Eligibility
- Request Prior Authorization
- View the Gaps in Care Report
- Add/Edit Portal Users
- And much more
Referrals and MPC
Please note that MPC does not require referrals for specialist care.
Keep Us Informed
MPC needs to be notified if your practice is unable to accept new members. It is important that we have accurate information in our provider directory as members use the directory to select practitioners. By providing updated information, you can assist MPC in providing the best care we can for our members. It is also important for us to know if you plan to move, change phone numbers, or change your network status. Call 1-800-953-8854 to update or verify your contact information or status. You can also check your information on our secure provider portal. Please let us know at least 30 days before you expect a change to your information.
Visit Our Website
Find information on:
- Quality Improvement Programs
- Population Health Management Programs
- Care Management Programs
- Health & Wellness Programs
- Clinical Practice Guidelines
- Utilization Management, including decision-making criteria, affirmative statement, and staff availability
- Pharmacy and Prescription Drug Management
- Benefits and Coverage
- Member Rights and Responsibilities
- Protected Health Information Use and Disclosure
- Provider Manual
- Member Handbook
- Provider Directory
- Credentialing Rights
If you do not have internet service, you can reach us by phone (numbers listed in “Who to Call” – below) for more information.
WHO TO CALL
PROVIDER SERVICES
Claims status, network participation, member eligibility, access language services during patient encounters, etc.
800-953-8854
MARYLAND HEALTHY SMILES DENTAL PROGRAM
855-934-9812
PUBLIC MENTAL HEALTH SERVICES
800-888-1965
SUPERIOR VISION
800-428-8789
UTILIZATION MANAGEMENT
800-953-8854
CARE MANAGEMENT
800-953-8854
HEALTH EDUCATION REQUESTS
800-953-8854
RETAIL PHARMACY MEDICATION UM
888-258-8250
Published on: September 3, 2026