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Health Information Technology   Preauthorization  

Electronic Preauthorization

Overview

Md. Code Ann., Health-General Article § 19-108.2, (law) established four benchmarks, which aim to create administrative efficiencies in the preauthorization process by eliminating paper-based processes and enabling the electronic submission of preauthorization requests. The law required MHCC to work with State-regulated insurers, nonprofit health service plans, health maintenance organizations and pharmacy benefits managers (PBMs) (collectively “payors”) and providers to attain the benchmarks. 

Benchmark 1 - Payors establish online access for providers to a listing of medical services and pharmaceuticals requiring preauthorization and the key criteria for making a determination.

Benchmark 2 - Payors establish an online system to receive preauthorization requests electronically from providers and assign a unique identification number to each request for tracking purposes.

Benchmark 3 - Payors process all electronic preauthorization requests within established timeframes – for pharmaceuticals, in real-time or within one business day upon receiving all pertinent information; and for medical services, within two business days upon receiving all pertinent information. 

Benchmark 4 - Payors establish an electronic process that allows providers to override a step therapy or fail-first protocol when submitting an electronic pharmaceutical preauthorization request.

Implementation

The law required MHCC to report annually to the Governor and General Assembly through 2016.  The final report submitted by MHCC can be accessed here.

Information for Providers

Information on preauthorization and access to the online systems follow:  For more information, contact the individual payor or PBM.

Payors

1.   Aetna          

2.   CareFirst BlueCross BlueShield          

3.   Cigna Healthcare Mid-Atlantic Region          

4.  UnitedHealthcare        

PBMs

  1. CVS Caremark  
  2. Express Scripts  
  3. Optum Rx   

Benchmark Waiver Requests

The law gave MHCC authority to adopt regulations to establish a process by which a payor may be waived from attaining one or more of the benchmarks.  COMAR 10.25.17.05 details the waiver process.  All initial waiver requests or requests to renew a waiver should be submitted to Justine Springer at justine.springer@maryland.gov 


Last Updated: 5/28/2024