Maryland medical billing and payer rules

Timely filing in Maryland

Maryland law and the federal No Surprises Act

Maryland sets the out-of-network rate for hospital services, for HMO enrollees and for on-call and hospital-based physicians with an assignment of benefits. Federal IDR covers the rest, and self-funded plans generally follow the federal process.

Major payers

How does Maryland Medicaid work for billing?

Maryland's Medicaid program sits inside the Maryland Department of Health (MDH), and most members receive care through HealthChoice, the state's managed care program. A claim for a HealthChoice member goes to the member's managed care organization (MCO), not to the state.

Fee-for-service claims go to MDH. Its guidance describes eMedicaid as a secure portal where a provider can view the remittance advice, submit CMS-1500 claims and check claim status. EDI senders enroll in Maryland Medicaid Electronic Exchange testing, and paper claims go to the Claims Processing Division. MDH publishes a CMS-1500 manual for professional claims and a UB-04 hospital manual for institutional claims. All provider payments are made by electronic funds transfer through the Comptroller of Maryland, so bank changes are filed with the Comptroller's EFT program.

Which MCOs are in HealthChoice?

The MDH HealthChoice comparison chart lists nine plans: Aetna Better Health, CareFirst BlueCross BlueShield Community Health Plan Maryland, Jai Medical Systems, Kaiser Permanente, Maryland Physicians Care, MedStar Family Choice, Priority Partners, UnitedHealthcare Community Plan and Wellpoint Maryland. Each plan's own provider manual holds its claim rules. Behavioral health is split out: MDH states that its administrative service organization, Carelon, must authorize behavioral health services. Our Kaiser Permanente billing guide covers one of the nine.

How do you enroll or revalidate?

MDH says a provider who wants to bill Medicaid must enroll as a participating provider through the Maryland Provider Registration and Information Management Enterprise (MPRIME). The same portal handles re-enrollment, revalidation and updates, so check it whenever a location, tax ID or ownership detail changes.

What is the Maryland Medicaid timely filing limit?

A fee-for-service claim must be received by Maryland Medicaid within 12 months of the date of service. COMAR 10.09.36.06B(3)(a) sets that limit and counts from the date of discharge for a hospital inpatient service, or from the month of service for a nursing or rehabilitation facility or hospice. A claim counts as received when the Program signs for a certified mail parcel or the claim appears on your remittance advice. A claim waiting in a clearinghouse queue has not been received.

MDH tells providers to send a cover letter explaining a late submission, with the documentation, by mail to the provider relations unit rather than through eMedicaid.

What about HealthChoice MCOs?

The 12 months belong to MDH and fee-for-service. MDH says that for MCO billing requirements you contact the participant's MCO, and this page cites no statewide filing number for the nine plans. We load each plan's window from its provider manual at onboarding and track it as a separate clock.

MDH states that a claim denial is a contract issue between the MCO and the provider, and that it cannot compel an MCO to pay. The state's independent review organization hears medical necessity denials only, after the MCO's appeals, for a $425 fee (July 2022 template manual).

What does the law give you against commercial insurers?

Under Insurance Article § 15-1005(e), a plan must allow at least 180 days from the date of service to submit a claim and at least 90 working days after a denial to appeal. If a plan wrongly denies a timely claim because of a processing error and you tell it within 1 year, it must reprocess the claim without a resubmission.

Who is the Medicare contractor in Maryland?

Novitas Solutions is the Medicare Administrative Contractor (MAC) for Part A and Part B claims in Maryland. The CMS list of MACs by state puts Maryland in Jurisdiction L (JL), with Delaware, the District of Columbia, New Jersey and Pennsylvania. The Medicare billing guide covers the mechanics.

Under 42 CFR 424.44(a)(1), a Medicare claim for services on or after January 1, 2010 must be filed within 1 calendar year after the date of service.

How does Maryland's all-payer hospital rate setting affect billing?

Maryland is the one state where a state commission sets hospital rates for every payer. The Health Services Cost Review Commission (HSCRC) has jurisdiction over hospital services offered by all facilities under Health-General Article § 19-211(a), and a facility must charge only at a rate set under that subtitle (§ 19-219(b)(2)). Section 19-212 tells HSCRC to certify each facility's rates, to assure rates are set equitably among all purchasers, and to develop global budget guidelines under the State's all-payer model contract.

What does that mean for a claim?

Three points follow. A rate schedule change needs written notice to HSCRC, effective at least 30 days after filing (§ 19-222(a)). COMAR 31.10.11.02 lists, as the code set for hospital services under a Maryland contract or policy, a revenue code approved by HSCRC for a hospital in the State. And an HMO must pay a non-contracted hospital at the rate approved by HSCRC (Health-General § 19-710.1(b)(2)(i)). Insurance Article § 15-1003(b) makes the NUBC form, the UB-04, the uniform hospital claim form.

What happened to the Total Cost of Care Model?

The Maryland Total Cost of Care Model ended on December 31, 2025. The CMS Innovation Center page says CMS announced the end on March 12, 2025, and that the model transitioned to the AHEAD model, whose implementation period began in January 2026. CMS lists Maryland as AHEAD Cohort 1, running through December 31, 2035. HSCRC's own site was not reachable, so check its notices before you model revenue.

For an out-of-network claim, CMS's May 18, 2022 letter says Maryland's All-Payer Model Agreement determines the rate for hospital services. Section 19-201(e) defines hospital services to include emergency services at a licensed freestanding medical facility, and § 19-211(c) has HSCRC set those rates. We read those together to mean facility emergency charges sit under HSCRC rate setting, not federal IDR.

What is Maryland's prompt payment law?

Maryland requires an insurer, nonprofit health service plan or health maintenance organization to pay or send a status notice within 30 days of receiving a claim. The rule is Insurance Article § 15-1005(c), and it covers claims from practitioners and from hospitals and related institutions.

Interest must be included in the late payment without a second claim from you (§ 15-1005(g)(2)), so a late payment that arrives without interest is itself a variance. A clean claim is defined by regulation: COMAR 31.10.11.02 requires the data elements for a practitioner or hospital plus any attachments the payer requested under Regulation .10.

Section 15-1005 covers plans the Maryland Insurance Administration regulates. A self-funded plan under ERISA is not an insurer, so check the plan type before you cite it.

Does Maryland have its own surprise billing law?

Yes, in pieces. CMS's May 18, 2022 letter to Maryland describes three state payment methods that take the place of federal IDR where they apply: the All-Payer Model Agreement for hospital services, Health-General § 19-710.1 for HMOs, and Insurance Article § 14-205.2 for EPOs and PPOs. Federal IDR covers everything else.

The CMS Q&A on state laws says a state generally cannot enforce its protections against a self-insured group health plan unless the plan opted in. For a self-funded ERISA plan, plan on the federal process.

How does § 14-205.2 work for on-call and hospital-based physicians?

It applies to nonpreferred on-call and hospital-based physicians who obtain an assignment of benefits from the insured and notify the insurer as the Commissioner specifies. The assignment is the patient's written transfer of the right to be paid to the provider, so registration paperwork decides your pathway.

The insurer must pay within 30 days. For an on-call physician in a hospital, the floor is the greater of 140% of the average rate it paid contracted similar providers in the 12 months ending the previous January 1, or its 2010 average for non-contracted providers inflated by the Medicare Economic Index. For a hospital-based physician, the second test is the insurer's 2010 final allowed amount, inflated the same way, for the same tax ID the physician used in 2009.

The insured is not liable for covered services, and the physician may not collect or sue for money the insurer owes. The physician may collect deductible, copayment and coinsurance, non-covered services, and Medicare secondary balances up to the Medicare approved amount. The insurer must disclose the rate on request, a physician may complain to the Administration or sue, and the Commissioner may fine up to $5,000 per violation. See emergency medicine billing, anesthesia billing and radiology billing.

What does § 19-710.1 require from an HMO?

For a covered service from a provider with no written contract, the HMO must pay within 30 days. It pays a hospital at the HSCRC rate and a trauma physician at the greater of 140% of the Medicare rate or the rate it paid as of January 1, 2001. Other providers get at least 125% of the average contracted rate, and for evaluation and management services the greater of that or 140% of the August 1, 2008 Medicare rate inflated by the Medicare Economic Index.

What about uninsured and self-pay patients?

CMS says Maryland's own process under Commercial Law § 13-4A-01 does not meet federal minimums, so the federal patient-provider dispute resolution process applies. A self-pay patient billed far above a good faith estimate has 120 calendar days to start it. This is the 2022 position, and no later Maryland letter is cited here. Our state surprise billing laws page compares states.

How do you dispute an out-of-network underpayment in Maryland?

Decide which pathway the claim belongs to, then use it: HSCRC rates for facility services, § 19-710.1 for an HMO enrollee, § 14-205.2 for a physician with an assignment of benefits, or federal open negotiation and IDR for the rest.

Our out-of-network billing and IDR service runs these steps.

Which payers matter most in Maryland?

Official sources let us name the nine HealthChoice MCOs, Medicare through Novitas, and CareFirst, which the CMS Innovation Center page says CMS selected as an aligned payer in Maryland's primary care program from January 2020. This page cites no Maryland Insurance Administration market share reports, so we name and rank no other commercial carriers. See the Medicaid billing guide for program-level rules.

How we handle billing in Maryland

We sort each Maryland claim by pathway first: HealthChoice MCO, fee-for-service Medicaid, Novitas JL or commercial. Hospital claims are checked for HSCRC-approved revenue codes, and physician claims for the assignment of benefits that § 14-205.2 needs. Fee-for-service Medicaid carries a 12-month clock, and each MCO gets its own.

For underpaid out-of-network claims we run open negotiation and federal IDR from first notice to final payment, and we build the state argument where § 14-205.2 or § 19-710.1 applies. Book a call and we will review your Maryland payer mix first.