Provider Resources

Presented on this page are helpful resources for providers.

If there is a resource that you do not see listed on this page, please feel free to contact our Provider Relations Department today for assistance.

Electronic Resources

HealthChoice Diabetes Prevention Program
ICD-10 Resources

ICD10 Claims Processing
In efforts to ensure proper claims processing for inpatient claims and outpatient claims for dates of service beginning October 1st, 2015, all providers must provide a valid ICD-10 diagnosis code to the Jai Medical Systems Utilization Management Department upon notification of all Inpatient admissions and request for all outpatient services. Failure to provide the UM department a valid ICD-10 code could result in a delay or denial in payment. For all questions or inquiries regarding this matter please contact Laurie Hopple at 410-433-5600 option 16 or Amber Mathur at 410-433-5600 option 22. Thank you.

Frequently Asked Questions
Please refer to our FAQ document for additional information about the transition to ICD-10.

Clearinghouse Trading Partners
Jai Medical Systems currently partners with SSI Claimsnet to provide electronic billing services for professional and institutional claims. Electronic claims submission improves billing and collection by reducing lag time between claims submission and payer processing. Utilizing a clearinghouse can also reduce the cost of paper transactions and postage costs.
Visit this page for more information about registering with SSI Claimsnet to start sending electronic claims data.

Provider Data Exchange Form

Provider Quick Reference Guide

Provider Manual – As of 2023
Access to our Provider Manual and Provider Portal is available for our participating providers. Please contact our Provider Relations Department if you require assistance in accessing our Provider Manual and/or Provider Portal.

Clinical Guidelines

HEDIS Quick Reference Guides 
Please review the following HEDIS Quick Reference guides. These guides include the recommended care for adult and pediatric patients based on MY 2022 HEDIS measures.

HEDIS Quick Reference 7.22 – PEDS
HEDIS Quick Reference 7.22 – ADULTS

Print Provider Directory

New Provider Orientation

General Medicaid Provider Information

For general Medicaid provider information, including forms, updates, fee schedules, and billing instructions, please visit the Maryland Department of Health’s website.

UM Criteria

Standard Prior Authorization Form

All services requiring prior authorization, as outlined in the ‘Prior Authorization Guidelines’ below, require a Standard Authorization Request Form to be completed by the member’s Primary Care Provider and submitted to the Utilization Review and Case Management Department for review and approval. This form does not replace the Jai Medical Systems Referral Form and is not a valid document for claim submission purposes.

Additional Instructions for completing the Standard Prior Authorization Request Form

Requesting Provider (Physician) refers to the provider who is ordering the procedure or service and is following the patient’s care for this condition. Please include the best phone number for contacting the physician or office representative for any additional questions.

Place of Service/Servicing Provider refers to the facility and provider who is performing the procedure or providing the service (i.e., hospital/facility). Please include the best phone numbers for contacting the physician or office representative for any additional questions.

Procedure/Service Requested all diagnosis codes/CPT codes/HCPCS codes along with the written description of all listed codes are required.

Prior Authorization Guidelines

Lab Services Requiring Prior Authorization 

Non-Invasive Prenatal Testing (NIPTs) Clinical Criteria
As recently shared by the Maryland Department of Health regarding the NIPTs Clinical Criteria, Jai Medical Systems has added CPT 81420 and 81507 as covered services without the need for a Prior Authorization.  We do require providers to utilize our preferred lab vendor, LabCorp, for this testing.

Utilization management decisions made by Jai Medical Systems Managed Care Organization, Inc. staff are based on the appropriateness of care and the availability of benefit coverage.  There are no financial incentives or rewards provided to Jai Medical Systems Managed Care Organization, Inc. staff for utilization management decisions, including for denials of coverage or underutilization of coverage benefits.

The clinical criteria used for making utilization management decisions is available for review in the Jai Medical Systems Managed Care Organization, Inc. administrative offices.  Practitioners may request a copy of the criteria that is used in making utilization management decisions by calling our Utilization Management Department at 1-888-JAI-1999.

Gender-Affirming Healthcare Services 

Member Rights and Responsibilities

Notice of Privacy Practices

Federal Deficit Reduction Act and False Claims

Important Tools for Primary Care Providers regarding HPV Vaccination Rates

Please review the resources provided by both the Maryland Department of Health as well as the CDC to assist in your HPV vaccination efforts.

Increasing the Uptake of the HPV Vaccine in Maryland
CDC – Teen Vaccine Uptake

Cultural Competency Education for Providers

We encourage you to check out the links below for information regarding the competencies for providers when it comes to treating a diverse population.

Think Cultural Health

Affirmative Care for Transgender and Gender-Nonconforming People: Best Practices for Front-line Health Care Staff.”

The Respect Model

Maryland Behavioral Health Training