Maryland Billing Reference

Medical Billing in Maryland: HealthChoice, Payer Landscape & Timely Filing

The working reference for Maryland billing teams: who the payers are, how HealthChoice managed care is structured, and the filing windows that govern your claims. Updated July 2026.

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Medical Billing in Maryland: The Short Version

Maryland HealthChoice has operated as a managed care program since 1997 — one of the longest-running state Medicaid managed care programs in the US. Nine MCOs participate in HealthChoice, each with its own timely filing window (commonly 180 days, even though state FFS allows 12 months). CareFirst BlueCross BlueShield is the dominant commercial insurer for Maryland, DC, and Northern Virginia, and also operates a HealthChoice MCO — billing teams must distinguish commercial CareFirst from CareFirst Community Health Plan (Medicaid) and use separate payer IDs. Kaiser Permanente Mid-Atlantic is a major integrated system with dominant government employee (FEHBP) market presence.

Payer Landscape

Major Payers in Maryland

Payer	Type	What Billing Teams Should Know
CareFirst BlueCross BlueShield	Commercial / Blues Plan / MA	Dominant commercial insurer for Maryland, DC, and Northern VA. Also operates CareFirst Community Health Plan (HealthChoice MCO) — completely separate payer IDs, fee schedules, and portals for commercial vs. Medicaid
Kaiser Permanente Mid-Atlantic	Integrated HMO	Major integrated system in suburban MD, DC, and Northern VA. Dominant government employee (FEHBP) market. Also participates as a HealthChoice MCO. Non-Kaiser providers require specific Kaiser authorization workflows
UnitedHealthcare	Commercial PPO/HMO / MA	Statewide commercial and Medicare Advantage presence. Standard 90-day commercial timely filing. Also participates as UHC Community Plan (HealthChoice MCO)
Aetna (CVS Health)	Commercial PPO/HMO / MA	Significant employer-sponsored and ACA marketplace presence. Aetna Better Health is its HealthChoice MCO subsidiary. Separate workflows for each
Cigna / Evernorth	Commercial PPO	Employer-sponsored, large group market. Strong in Baltimore and suburban MD. Standard 90-day in-network timely filing
Maryland Medicaid (HealthChoice)	Medicaid (via MCOs)	State FFS: 12 months. HealthChoice MCOs: commonly 180 days per individual contracts. Always verify with the specific MCO's provider manual

Medicaid Structure

Maryland HealthChoice: Managed Care Plans (2026)

Administered by the Maryland Department of Health (MDH), Medical Care Programs Administration. HealthChoice has operated since 1997. Nine MCOs are contracted for the 2026 period. Priority Partners had NCQA enrollment suspended March 17–May 16, 2025 — verify current status.

Plan	Notes
Aetna Better Health of Maryland	CVS Health / Aetna Medicaid subsidiary. Statewide. 2026 Provider Manual updated January 2026
CareFirst Community Health Plan Maryland	CareFirst BCBS's Medicaid product. Significant presence in Central Maryland / Baltimore. Separate from commercial CareFirst
Jai Medical Systems	Local Maryland for-profit plan. Strong NCQA performance ratings
Kaiser Permanente Mid-Atlantic States	4.5-star NCQA rated. Integrated delivery model; serves Kaiser network members only
Maryland Physicians Care	Local for-profit HealthChoice plan
MedStar Family Choice	Subsidiary of MedStar Health system. Baltimore-region focus
Priority Partners	Joint venture between Johns Hopkins Medicine and Johns Hopkins HealthCare. Enrollment paused March 17–May 16, 2025 due to NCQA suspension — verify current status before submitting claims
Amerigroup Maryland / Wellpoint	Elevance Health subsidiary. Statewide participation
UnitedHealthcare Community Plan	National MCO, statewide HealthChoice participation. Separate from commercial UHC

Filing Deadlines

Timely Filing Limits for Maryland Claims

State FFS Medicaid allows 12 months — but most Maryland Medicaid patients are in HealthChoice managed care, where MCO contracts commonly set 180 days. Verify with each MCO's current provider manual.

Payer	Timely Filing Limit	Notes
Maryland Medicaid (FFS)	12 months (365 days)	Applies only to fee-for-service Medicaid — a small fraction of MD Medicaid members. Most are in HealthChoice managed care
HealthChoice MCOs	Commonly 180 days (MCO-specific)	Each MCO sets its own timely filing in its provider contract. Aetna BH MD: 180 days per 2026 manual. Verify all nine MCOs separately
Medicare (Original)	12 months from date of service	Federal standard (42 CFR §424.44); no contract variation
UnitedHealthcare (Commercial)	90 days from date of service	Standard commercial; some contracts allow up to 180 days. Verify specific agreement
Aetna (Commercial)	90 days in-network; 12 months out-of-network	Verify current contract terms
Cigna (Commercial)	90 days in-network; 180 days out-of-network	Standard commercial Cigna policy
CareFirst BCBS (Commercial)	180 days (commercial)	Verify specific product and contract. CareFirst Medicaid MCO follows HealthChoice contract terms separately

Verified against payer publications (July 2026). Filing limits change by contract and plan year — treat this table as a starting point, not a substitute for the payer manual.

MD-Specific Rules

Maryland Billing Realities to Know

MCO Timely Filing Differs from State FFS

Maryland's state FFS Medicaid program allows 12 months, but each HealthChoice MCO negotiates its own timely filing in its provider contract — commonly 180 days. Billing teams managing multiple MCOs must maintain a payer-specific timely filing calendar. Do not assume the state's 12-month window applies to MCO claims.

Priority Partners NCQA Suspension (2025)

Priority Partners MCO (the Johns Hopkins-affiliated HealthChoice plan) had NCQA accreditation suspended, pausing new member enrollment March 17–May 16, 2025. While enrollment resumed, providers should verify patients currently assigned to Priority Partners remain enrolled and that the plan's operational status is confirmed before submitting claims.

CareFirst Operates Both Commercial and Medicaid

CareFirst BCBS is the dominant commercial insurer for Maryland and also operates CareFirst Community Health Plan as a HealthChoice MCO. These are separate entities with different payer IDs, fee schedules, and authorization pathways. Never mix commercial CareFirst claims with CareFirst Community Health Plan Medicaid claims — the same parent company operates completely different billing workflows for each.

Kaiser Mid-Atlantic's Integrated Model

Kaiser Permanente Mid-Atlantic is a significant payer and provider in Maryland with particular dominance in government employee markets (FEHBP). Non-Kaiser providers billing Kaiser-insured patients must use Kaiser-specific authorization workflows. Kaiser's integrated model means they maintain their own fee schedules and formulary distinct from commercial carriers — verify Kaiser-specific requirements before rendering authorized services.

Frequently Asked Questions

Maryland's state fee-for-service Medicaid program allows 12 months (365 days) from the date of service. However, if a patient is enrolled in a HealthChoice managed care plan — which covers the vast majority of Maryland Medicaid members — the timely filing limit is set by that MCO's provider contract, commonly 180 days. Always consult the specific MCO's provider manual. Do not rely on the state FFS limit if your patient is in managed care.

Eligibility verification through MDH's MMIS eligibility system or your clearinghouse will show whether the patient is enrolled in a HealthChoice MCO or fee-for-service Medicaid. Most Maryland Medicaid patients are in HealthChoice managed care. If the patient has an MCO assigned, bill the MCO directly using that MCO's payer ID, not the state Medicaid fiscal agent.

Priority Partners MCO was subject to an NCQA accreditation suspension that paused new member enrollment from March 17 to May 16, 2025. New member enrollment has since resumed. For billing purposes, the suspension did not affect ongoing claims processing for existing members during the suspension period. Providers should confirm current patient assignment and plan status before submitting claims, particularly for patients who may have been reassigned during the suspension period.

No. While both are under the CareFirst umbrella, CareFirst BlueCross BlueShield (commercial) and CareFirst Community Health Plan Maryland (HealthChoice Medicaid MCO) are separate entities with different payer IDs, portal access, fee schedules, and prior authorization requirements. Claims submitted under the wrong payer ID will route incorrectly and may be denied. Always verify payer ID based on the patient's coverage type.