Maryland Medicaid: Balance billing is not permitted

Check member eligibility and benefits before providing services

We want to remind you that balance billing members in Medicaid programs and eligible dual plans is not permitted. You can help eliminate balance billing and remain compliant with the Maryland Department of Health, federal Medicaid requirements and your UnitedHealthcare Community Plan Provider Agreement by verifying member eligibility and benefits before you provide services.

What this means for you

You may not balance bill members if:

• The charge amount and the UnitedHealthcare Community Plan fee schedule differ
• Your claim is denied for late submission, unauthorized service or as not medically necessary
• UnitedHealthcare Community Plan of Maryland is reviewing a claim

Balance billing members for covered services may result in payment recoupment, sanctions and/or termination from the Maryland Medicaid program.

What you need to do

Follow these best practices to help ensure price transparency with members: 

• Verify member eligibility and inform them in advance which services are covered and noncovered under Maryland Medicaid, and whether they may have any financial responsibility
• Maintain accurate health insurance information in all billing systems
• Collect only Maryland Medicaid-permitted cost-sharing, if applicable
•  Bill all other liable third parties first, as Maryland Medicaid is the payer of last resort. If the member has other medical coverage, that carrier is considered the primary payer. When billing UnitedHealthcare Community Plan, please submit the primary payer’s explanation of benefits or remittance advice with the claim, if applicable.

How to check member eligibility and benefits

You can verify member eligibility and determine member benefits through the UnitedHealthcare Provider Portal:

• Sign in to the UnitedHealthcare Provider Portal with your One Healthcare ID
  • If you don’t have a One Healthcare ID, register now
• Select Eligibility and enter your search criteria

To learn more about eligibility and benefits, view our training guide.

For more information

Visit our interactive guide Understanding Balance Billing for details on members’ rights, explanations specific to participating providers, non-participating providers and opted-out providers, and more.