Prior Authorization in Maryland

What is specific to Maryland

Maryland is the only state with all-payer hospital rate setting: a state commission sets hospital rates for every payer under a federal Medicare waiver instead of each plan negotiating separately.

Maryland’s Medicaid program is Maryland Medicaid (HealthChoice). Practices with a meaningful Maryland Medicaid (HealthChoice) mix usually need it worked as its own queue rather than mixed into commercial follow-up, because the submission path, the timely filing window and the appeal route are all different.

Medicare here is adjudicated by Novitas Solutions, jurisdiction JL — shared with Delaware and Pennsylvania, but not with Virginia (Palmetto GBA) or West Virginia (Palmetto GBA). CMS publishes the jurisdictions; checked September 2026.

What a prior authorization seat does in Maryland

Submitted before the date of service and chased through the payer's decision window.

An authorisation found after the visit is a write-off, not a denial to appeal. In Maryland the work is submitting ahead of scheduling and chasing the decision, against a payment clock that starts only once a clean claim lands.

• Authorizations submitted ahead of scheduling, not after
• Status chased rather than waited on
• Peer-to-peer reviews scheduled when required
• Clinical documentation gathered before submission
• Expiring authorizations flagged before they lapse
• Worked during Maryland business hours, not queued overnight

For the statute behind all of this — Maryland’s prompt-pay deadline, its Medicaid filing limit, and the wrinkle that catches people out here — see the Maryland billing page.

Maryland Medicaid (HealthChoice), in practice

HealthChoice is Maryland's mandatory Medicaid managed care program — members pick an MCO and are auto-assigned if they do not ("If you do not choose an MCO, the State will automatically assign you to an MCO", https://health.maryland.gov/mmcp/healthchoice/pages/home.aspx). The CY2026 official performance report card lists nine participating MCOs: Aetna Better Health, CareFirst BlueCross BlueShield Community Health Plan, Jai Medical Systems, Kaiser Permanente, Maryland Physicians Care, MedStar Family Choice, Priority Partners, UnitedHealthcare and Wellpoint Maryland. Source: health.maryland.gov

Maryland is an all-payer hospital rate-setting state: hospital prices are set by the Health Services Cost Review Commission, not negotiated payer by payer, so a Maryland hospital charges Medicare, Medicaid and every commercial plan the same rate for the same service. Statutory basis, verbatim from Md. Code, Health-General § 19-219: a hospital must "Charge for services only at a rate set in accordance with this subtitle" and "Comply with the applicable terms and conditions of the all–payer model contract", and "The rates are set equitably among all purchasers or classes of purchasers without undue discrimination or preference." Practical effect: contract-rate negotiation and payer-mix charge modelling on the hospital side are largely moot in Maryland; the leverage is in charge capture and HSCRC rate compliance instead. (Physician/professional claims are not rate-regulated.) Source: Maryland General Assembly

For authorisations it decides who you ask. A carve-out means the rules, the portal and the turnaround belong to a different administrator from the one handling the rest of the member’s care, and an authorisation obtained from the wrong one is not an authorisation.

How long you have to file a Maryland Medicaid (HealthChoice) claim

12 months from the date of service. Medicare-related claims: 12 months from the date of service or 120 days from the Medicare remittance date, whichever is later.

“The Department may not reimburse the claims received by the Program for payment more than 12 months after the date of service.” COMAR 10.09.36.06 — Billing Time Limitations

A claim past that date is not late, it is unpayable, and no appeal recovers it. It is the one queue where a week of nobody working it is money that does not come back — which is the argument for working Maryland Medicaid (HealthChoice) as its own queue rather than mixing it into commercial follow-up. Every state’s limit is listed here.

That date is also the outer edge of what a retrospective authorisation is worth. Payers will sometimes grant one after the fact, and practices treat that as the problem solved — but the claim still has to be filed inside the window above. An authorisation granted after it has closed is an administrative victory attached to money nobody can bill, which is why the authorisation queue and the filing clock have to be watched on the same screen rather than by two different people.

Working Maryland hours

Maryland runs on Eastern time, 10 hours behind our floor in Rawalpindi. To be at a desk for your nine to five, the shift here runs 7pm to 3am, and 6pm to 2am once the clocks go forward. Pakistan does not observe daylight saving, so the shift moves on this side rather than yours.

That is the part that decides whether follow-up happens at all: a payer’s phone lines are open on Maryland hours and nobody else’s.

What it costs in Maryland

$1,900

Per seat, per month, in US dollars — $22,800 a year for one full-time person, forty hours a week, on Maryland hours. No annual contract, no percentage of collections, no setup fee and no software to buy. Seat prices across all roles in Maryland run $1,500 to $2,500; the full list is published.

That is the entire invoice. Run your own figures against a percentage vendor or a hire rather than take ours.

Getting started in Maryland

About a week from a signed agreement to a person working your queue, and that week of training is not billed on top. The week, step by step, and what is signed before anyone has access.

If working with staff outside the United States is new to your practice, see how a medical billing company structures that seat and why offshore medical billing does not have to mean losing visibility into the work.

Questions