Legal Bulletins

Carelon Behavioral Health of Maryland, the administrative services organization managing Maryland Medicaid's public behavioral health system, recently issued an updated Public Behavioral Health System (PBHS) Provider Manual. The changes in Carelon's new PGHS Provider Manual directly impact provider authorization requirements, medical necessity criteria, and billing practices. 

Providers should review these changes carefully to ensure continued compliance, avoid administrative denials, and maintain timely reimbursement.

Key Updates

The updated Provider Manual includes significant revisions across several critical operational areas:

1. Authorizations (Chapter 5): The manual provides updated guidance on retroactive reviews, alongside new tips and support materials to streamline the authorization and concurrent review processes.
2. Medical Necessity Criteria (Chapter 6): Carelon has updated the medical necessity criteria and program description requirements for a broad spectrum of services.
3. Telehealth (Chapter 7): Recognizing the expanding role of remote care, Carelon has created a dedicated, new chapter on telehealth. Providers must ensure their telehealth practices align with both the updated manual and the Maryland medical assistance regulations governing standard program coverage COMAR 10.09.49.07 (2026).
4. Billing and Administrative Resources: The manual introduces several operational changes that affect daily billing and intake workflows:
   
   1. The Maryland Billing Appendix has been superseded and removed from the Carelon website. It should no longer be utilized.
   2. The Emergency Petition Guide is now a standalone document rather than part of the Billing Appendix, providing clearer access to procedures governing emergency evaluations.
   3. A new Explanation of Payment (EOP) Denial List with Claims Adjustment Reason Codes/ Remittance Advice Remark Codes (CARC/RARC) has been included. This resource is also available on the Carelon website under Provider Manuals & Billing Guides.

Next Steps

Behavioral health care providers who wish to protect their reimbursement streams and ensure strict compliance with Carelon's updated standards should take the following actions:

1. Download the updated PBHS Provider Manual and the new standalone Emergency Petition Guide from the Carelon website.
2. Review the specific medical necessity criteria in Chapter 6 that apply to your facility's licensed programs and update your clinical documentation templates accordingly.
3. Instruct your billing and administrative teams to discard the obsolete Maryland Billing Appendix and integrate the new EOP Denial List into their claims resolution workflows.

If you have questions about how these updated medical necessity criteria or telehealth requirements apply to your specific practice, please contact our office.

For more information concerning this topic, please contact Christopher P. Dean.

Contact Christopher P. Dean | 410-576-4249