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Maryland HealthChoice Program

Independent Review

 
The Department has contracted with Maximus Federal Services to resolve disputes about medical necessity claim denials between providers and HealthChoice MCOs.
 
Appeals Information 
 
 
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 first.
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 10.09.71.03. 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 https://mdiro.maximus.com/home.
 
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?
 
The review fee is $425. However, Maximus only charges after 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?
 
Maximus will not accept:
 
  •  Administrative denials
  • 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 
 
 
Maryland DHMH IRO Project and Case Portal Overview
 
To introduce providers to the IRO process, Maximus led two webinars on Wednesday, June 25, 2014 and Wednesday, February 4, 2015. To watch the recorded webinar and learn about how to use the portal, please click here​ or copy the following link into your web browser. You will need to complete a short registration form to view the recording.
 
 
Maximus Web Portal
The web portal works best with the Google Chrome and Mozilla Firefox web browsers. 
 
Provider Reference Guides
 
 
Visit the following MCO websites
for more provider information
 
For More Information
Ellen Mulcahy-Lehnert, Section Chief/Supervisor
Complaint Resolution Unit
Division of Outreach and Care Coordination
(410) 767-5703