Appeal Procedure Appeals related to Medical Assistance are conducted under the authorization of COMAR 10.09.36.09 and in accordance with COMAR 10.01.03 and 28.02.01. To initiate an appeal, the appeal must be filed within 30 days of receipt of a notice of administrative decisions in accordance with COMAR 10.01.03.06. Procedure Codes and Fee Schedules January 2017 EPSDT Acupuncture Services Procedure Code Description Requires Pre-Auth Maximum Number of Units Maximum Payment 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15-minutes of personal one-on-one contact with the patient N 1 $28.37 97811 Acupuncture without electrical stimulation, each additional 15-minutes of personal one-on-one contact with the patient, with of needle(s) N 1 $21.11 97813 Acupuncture with electrical stimulation, initial of personal one-on- one contact with the patient N 1 $30.27 97814 Acupuncture with electrical stimulation, initial of personal one-on- one contact with the patient, with re-insertion of needle(s) N 1 $23.86 EPSDT Chiropractic Services Procedure Code Description Requires Pre-Auth Maximum Number of Units Maximum Payment minutes minutes
92072 Fitting contact lens for management of keratoconus initial fitting $ 104.54 $80.01 92081 Visual field exam(s) limited $ 33.37 $ 33.37 92082 Visual field exam(s) Intermediate $ 49.38 $ 49.38 92083 Visual field exam(s) extended $ 56.74 $ 56.74 92100 Serial Tonometry exam(s) $ 63.33 $34.29 92132 Scanning Computerized ophthalmic diagnostic imaging anterior segment, with interpretation and report $ 30.41 $ 30.41 92133 Scanning Computerized ophthalmic diagnostic imaging posterior segment, with interpretation and report unilateral or bilateral; optic nerve $ 37.09 $ 37.09 92134 Scanning Computerized ophthalmic diagnostic imaging posterior segment, with interpretation and report unilateral or bilateral; retina $ 37.09 $ 37.09 92140 Glaucoma provaction tests w/o tonography $ 40.68 $18.79 92225 Ophthamoscopy, initial $ 20.98 $16.70 92226 Ophthamoscopy, subsequent $ 19.36 $14.80 92250 Fundus photography w/ interpretation and report $ 53.55 $ 53.55 92260 Ophthalmodynamoetry $ 14.48 $8.49 92283 Color vision examination extended, e.g., anomaloscope or equivalent $ 44.78 $ 44.78 92284 Dark adaptation examination w/ interpretation and report $ 51.16 $ 51.16 92285 External ocular photography w/ interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, $ 30.13 $ 30.13
Address SECTION II - Preauthorization General Information Pay to Provider Number Name Request Date Address Contact Provider’s Signature Telephone ( ) SECTION III – Additional Preauthorization Information Prescribing Provider Name Telephone ( ) Address SECTION IV – Preauthorization Line Item Information DESCRPTION OF SERVICE PROCEDURE REQUESTED DATES OF SERVICE AUTHOR. AMOUNT CODE MOD UNITS AMOUNT FROM THRU UNITS $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ PREAUTHORIZATION NUMBER DOCUMENT CONTROL NUMBER SUBMIT TO: Program Systems and Operations Administration (STAMP HERE) Division of Claims Processing P.O. Box 17058 Baltimore, Maryland 21203 SECTION V – Specific Preauthorization Information Patient Location: Home Nursing Home Hospital In-Patient Discharge Date