Provider News & Notices

At Jai Medical Systems, keeping our providers informed is our top priority.

At Jai Medical Systems, keeping our providers informed is our top priority.

Please review the information below for our newsletters, latest healthcare updates, and special announcements.

Jai Medical Systems Managed Care Organization, Inc. Provider Newsletter

Fall 2018 – VOLUME LXV

Jai Medical Systems Receives Highest National Rating for Third Year in a Row

We are pleased to announce that Jai Medical Systems is one of the Highest Rated Medicaid Health Insurance Plans in the United States for 2018-2019, according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Ratings. For 2018-2019, Jai Medical Systems earned a rating of 5 out of 5 in the NCQA Medicaid Health Insurance Plan Ratings for the THIRD consecutive year. No other Medicaid Health Plan has earned a rating of 5 out of 5 three years in a row. In addition, for the fourth year in a row, Jai Medical Systems has also earned NCQA’s highest Accreditation status of Excellent. We cannot achieve such high ratings without the assistance of our participating providers. Thank you for your participation and service to our members. For more information about our NCQA Accreditation and Health Plan Rating, please check out our press release at

Provider Network Expansion

In order to accommodate the growing needs of our members, Jai Medical Systems is expanding its provider network throughout the State of Maryland. Applications are now being accepted from primary care providers, specialty care providers, hospitals, specialty care networks, and ancillary care providers who are interested in joining our network. If you know any providers who may be interested in joining our network, please have them contact our Provider Relations Department at 1-888-JAI-1999 or via e-mail at

Provider Billing Tips

To ensure that your claims are processed quickly and accurately, please make sure to follow these simple guidelines regarding billing practices, referrals, and authorizations. Jai Medical Systems follows the Maryland Medicaid billing guidelines for claims billing. You may find a copy of the most recent Maryland Medicaid Billing Instructions at

When submitting the following type of claim, please ensure that you have appropriately followed the Maryland Medicaid Billing Instructions in addition to the below listed Jai Medical Systems claims submission guidelines:

Paper Claims

  • Please attach a valid, completely filled out, legibly written referral, outpatient authorization, or inpatient authorization, when applicable.
  • Please include the appropriate authorization number for the claim being billed in block 23 for the CMS1500 form and block 63 for the UB-04, when applicable.
  • Please attach a copy of the member’s primary insurance Explanation of Payment (EOP) or Remittance advice, when applicable.

Electronic Claims

  • Please fax one copy of a valid completely filled out, legibly written referral, outpatient authorization, or inpatient authorization, when applicable, to Jai Medical Systems’ Claims Processing Center at 1-866-381-7200, prior to claim submission.
  • Please ensure the authorization number, that is valid for the claim, is transmitted in the appropriate field on the electronic claim format.
  • Indicate any information regarding the member’s primary insurance and any payment made from the third party payer (TPP).

For more information regarding our billing guidelines, please visit our website at

Vaccinating Maryland’s Adolescents against HPV

We are asking for your help in addressing the State of Maryland’s public health initiative in immunizing Maryland’s adolescents against Human Papillomavirus (HPV). As you are aware, the HPV vaccine is very important because it protects against cancers caused by human papillomavirus infection. During this time of the year, many adolescents will be checking in with their Primary Care Providers for important well child checks and immunizations, such as the flu shot. If age-appropriate, please educate the parent and/or guardian about the importance of initiating and/or completing the HPV vaccination series. Recent studies have shown that a patient who receives a strong provider recommendation is four to five times more likely to receive the HPV vaccine.

Prescription Drug Monitoring Program Use Mandate

In 2016, as a response to the opioid crisis and an increase in overdose deaths, the State of Maryland passed HB 437, which created the Maryland Prescription Drug Monitoring Program (PDMP). The goal of the PDMP was to help prescribers identify and prevent prescription drug abuse.

Since its creation, opioid prescribing providers have been required to be registered with the PDMP before obtaining a new or renewing a controlled dangerous substance registration. In addition, since July 1, 2018, Maryland’s PDMP Use Mandate has taken effect. The PDMP Use Mandate requires prescribers to request and assess PDMP data under the following circumstances:

  • Before beginning a new course of treatment with an opioid or benzodiazepine, or
  • When a course of treatment with an opioid or benzodiazepine extends beyond 90 days. In this case, prescribers must query again at least every 90 days thereafter before prescribing or dispensing the opioid or benzodiazepine.

To comply with these requirements, prescribers must document in the patient’s health record that the PDMP data was requested and accessed prior to prescribing any opioid or benzodiazepine. For more information regarding the PDMP Use Mandate or how to register to access PDMP data, please refer to the Maryland Department of Health’s website at

Mandatory Generic Substitution

In order to manage care and limited healthcare resources, Jai Medical Systems requires a mandatory generic substitution for all medications, including over-the-counter (OTC) medications. Further, Jai Medical Systems has a benefit limitation of $50 for all OTC medications, including but not limited to, multivitamins. If you have any questions regarding our formulary and/or our mandatory generic substitution policy, please feel free to contact us today at 1-888-JAI-1999.

Visit Us Online

There are many online services available for our members and providers. Many of the resources listed in the chart on the left are available on our website at

If you prefer, all of this information is also available in print and by telephone. You may request this information by calling Jai Medical Systems at 1-888-JAI-1999.

Updates and Reminders:
  • Electronic Claims Submission: To submit claims electronically, providers must register with ClaimsNet website at 

    When applicable, prior to submitting your claims, please fax the appropriate authorization or referral to Fax Number: 1-866-381-7200.

  • Provider Portal: Participating providers are encouraged to utilize our Provider Portal to inquire about member eligibility, claim status, appeal status, and much more. To begin using our Provider Portal, please visit our website at

  • Prior Authorization Guidelines: Jai Medical Systems requires a prior authorization (PA) be obtained for certain services and procedures. Prior to submission of a PA request, approval for the applicable procedure must be received from the Primary Care Provider. For a listing of procedures and services requiring a PA, please visit our web-site at If you do not see a procedure or service listed or would like to see if a PA may be required, please feel free to contact our Utilization Management Department at 1-888-JAI-1999.

  • 24 Hour Nurse Advice Line: Please inform members about our 24 Hour Nurse Advice Line. To access, members should call 1-844-259-8613.

  • Claims Appeal Timeframes: Please note that providers have 180 calendar days to submit a first level appeal from the date of Explanation of Payment for the claim in question. Providers have 30 calendar days to submit a second level appeal from the date of the first level appeal’s determination letter. Providers have 85 business days to submit a third level appeal from the date that the first level appeal was received.