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Maryland HealthChoice Program
The Department has contracted with Maximus Federal Services to resolve disputes about medical necessity claim denials between providers and HealthChoice MCOs.
My claim is a medical necessity issue, and I think the MCO’s denial is wrong.
What do I do next?
Complete all internal MCO appeals
You must first work with the MCO to resolve the medical necessity dispute. Each MCO’s internal appeals process for providers follows the guidance in COMAR
. MCOs are responsible for resolving provider appeals within 90 business days of the initial filing, regardless of how many appeal levels are set.
If your appeal does not complete all levels of the MCO internal appeals process, Maximus will not review your case. Be sure to meet all appeal filing deadlines!
Receive and review your final appeal decision letter.
Once you receive this letter from the MCO, and the reason listed is related to medical necessity, you can file your case with Maximus.
Visit the Maximus web portal.
You have 30 calendar days from the date of the final appeal decision letter to file a case.
Access the web portal via
The entire review process is online. Once you register an account, you must sign and upload a case review agreement. From there, you can upload your final appeals decision letter. Maximus will request the appeals record from the MCO. Once the MCO sends the record, Maximus will resolve the dispute within 30 calendar days.
Download the Quick Reference Guide in the References and Resources section to learn how to use the portal to file cases, review past cases, make payments, and more.
How much does it cost
to file a case with Maximus?
During the initial year of the contract, the review fee is $325 per case. The case review fee will increase by $10 each subsequent year on the 15th of October. Please see fee schedule below.
Annual Fee Increase Schedule
Oct. 15, 2019 - Oct. 14, 2020:
Oct. 15, 2020 - Oct. 14, 2021:
Oct. 15, 2021 - Oct. 14, 2022:
Oct. 15, 2022 - Oct. 14, 2023:
Oct. 15, 2023 - Oct. 14, 2024:
Maximus only charges
making the case determination. If Maximus upholds the MCO’s denial, you must pay the fee. If Maximus reverses the MCO’s denial, the MCO must pay the fee. The web portal will walk you through submitting payments.
What cases do not qualify
for independent review?
Bundled claims with similar issues
Cases that have not completed all levels of internal MCO appeals (If you fail to meet the MCO internal appeals deadlines, Maximus will not review your case.)
Claims unrelated to HealthChoice recipients
What if I disagree
with the determination from Maximus?
If you choose to use this review process, you agree to give up all appeal rights (e.g., administrative hearings, court cases).
What if I have a medical necessity case that involves behavioral health
If your case has behavioral health elements, you should use the MCO/Value Options Dispute Resolution Committee process. For more information, see the
MCO/VO Dispute Resolution Committee Review Form
References and Resources
Maximus Web Portal
The web portal works best with the Google Chrome and Mozilla Firefox web browsers.
Provider Reference Guides
Quick Reference Guide for Providers
Quick Reference Guide for Managed Care Organizations
Visit the following MCO websites
for more provider information
Aetna Better Health of MD
Amerigroup Community Care
Jai Medical Group
Maryland Physicians Care
Medstar Family Choice
University of Maryland Health Partners
For More Information
Bernadette A Benta, MSHA, BSN, RN
HealthChoice Complaint Resolution
201 W. Preston Street, Baltimore, MD 21201-2399
(410) 767-6500 or 1-877-463-3464
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