Priority Partners 2016-2017

Introduction to the Provider Manual HealthChoice is Maryland’s Medicaid managed care program. Overseen by the Maryland Department of Health and Mental Hygiene (DHMH), the HealthChoice program serves most Medicaid participants. These individuals are enrolled in one of the participating Managed Care Organizations (MCOs). Each MCO has policies and procedures that providers who deliver services to members must adhere to. While each MCO has its own policies and procedures, many program elements apply to all providers, regardless of the MCO. The purpose of this manual is to explain those program elements and be a useful reference for providers who participate in the HealthChoice program. This manual is divided into seven sections: SECTION I – General Information. This section provides general descriptive information on the HealthChoice program including, but not limited to, program eligibility, MCO reimbursement policies, continuity of care and transportation. SECTION II – Provider Responsibilities. This section discusses expectations of all providers, regardless of MCO affiliation. SECTION III – HealthChoice Benefits and Services. This section provides a listing of the benefits that are and are not the responsibility of all MCOs that participate in HealthChoice. This section briefly outlines some of the optional benefits that Priority Partners may provide. This section also identifies benefit limitations and services that are not the responsibility of Priority Partners. SECTION IV – Rare and Expensive Case Management (REM). Members with certain diagnoses may disenroll from Priority Partners and receive their services through the REM program. This section details the REM program. SECTION V – DHMH Quality Improvement Program and MCO Oversight Activities. DHMH conducts numerous quality improvement activities for the HealthChoice program. This section reviews DHMH’s quality improvement activities. These activities are separate from quality improvement activities that Priority Partners may engage in. SECTION VI – Corrective Managed Care. This section discusses the steps that should be

taken if a member is determined to have abused MCO pharmacy benefits. SECTION VII – Additional Priority Partners Information.

Provider Manual 2016-2017


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