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    Maryland Department of Health
    Maryland Medicaid Administration

    ​​

    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 10.67.09.03. 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/mdiroportal/
     
    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:  $325
    Oct. 15, 2020 - Oct. 14, 2021:  $335
    Oct. 15, 2021 - Oct. 14, 2022:  $345
    Oct. 15, 2022 - Oct. 14, 2023:  $355
    Oct. 15, 2023 - Oct. 14, 2024:  $365
     
     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 Department of Health
    IRO Project
     
    To Introduce providers to the IRO process, Maximus has provided an Informational Flyer.  To view the Information Flyer, please click (here).  
     
    Maximus Web Portal

    https://mdiro.maximus.com/mdiroportal/                                                                  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
    Bernadette A Benta, MSHA, BSN, RN
    Division Chief
    HealthChoice Complaint Resolution
    410-767-5703