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 News and Notices

COVID-19 Special Notice: Temporary Admission Notification and Utilization Management Requirement modifications effective January 7, 2022.
Jai Medical Systems recommends hospitals follow our standard concurrent review notification requirements and procedures when possible.  However, based on current pandemic related circumstances and utilization, Jai Medical Systems is providing administrative flexibilities regarding notification requirements and concurrent review. These flexibilities are effective with dates of service beginning January 7, 2022, and will remain in effect until February 15, 2022.  If necessary, these administrative flexibilities may be extended.

It is our expectation that all admissions and discharges be reported in a timely manner. Ongoing concurrent review should occur as frequently as possible but may be delayed when necessary. Jai Medical Systems will not deny claims based on delayed concurrent review during this time. The purpose of Jai Medical Systems concurrent review is to ensure the appropriate use of limited healthcare resources while ensuring standards of care are met.

As always, Jai Medical Systems will assist with discharge planning and post-acute care coordination. Please provide notification prior to discharge to ensure proper discharge planning and post-hospitalization care coordination.

During this time, we understand that there may be a need for our members to be transferred to another hospital or post-acute facility for care. In these instances, we request that hospitals notify us as soon as possible regarding the transfer so that we may continue to coordinate care and discharge planning.

Pre-Certification of Elective Procedures is still required for payment. It is assumed that elective procedures will be limited while flexibilities are in place.

Winter 2021 – VOLUME LXXII

We are pleased to announce that Jai Medical Systems Managed Care Organization, Inc. is once again one of the Highest Rated Medicaid Health Insurance Plans in the United States for 2021-2022, according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Report Card. For 2021-2022, Jai Medical Systems earned a 5 out of 5 star rating from NCQA. In fact, Jai Medical Systems is the only Medicaid Health Plan in the United States to earn a 5-star rating from NCQA consecutively since 2016.

We cannot achieve such high ratings without the hard work and assistance of our participating providers. Thank you for your participation and service to our members. For more information about our NCQA Health Plan Rating, please check out our press release at

COVID-19 Vaccine News

The Food and Drug Administration’s (FDA) authorization and CDC’s recommendation for use are important steps forward as we work to stay ahead of the virus and keep Americans safe.

For individuals who received a Pfizer-BioNTech or Moderna COVID-19 vaccine, the following groups are eligible for a booster shot at 6 months or more after their initial series:

  • 65 years and older
  • Age 18+ who live in long-term care settings
  • Age 18+ who have underlying medical conditions
  • Age 18+ who work or live in high-risk settings

For the nearly 15 million people who got the Johnson & Johnson COVID-19 vac-cine, booster shots are also recommended for those who are 18 and older and who were vaccinated two or more months ago.

There are now booster recommendations for all three available COVID-19 vaccines in the United States. Eligible individuals may choose which vaccine they receive as a booster dose. Some people may have a preference for the vaccine type that they originally received, and others may prefer to get a different booster. CDC’s recommendations now allow for this type of mix and match dosing for booster shots. For more information, please visit

Maryland Prenatal Risk Assessment

The Maryland Prenatal Risk Assessment (MPRA) process helps to identify women who have medical, nutritional, and psychosocial predictors of poor birth out-comes, and allows the patient, local health department, provider, and MCO to work together to promote the best possible birth outcome. The MPRA process is a key policy initiative that strengthens the linkage of the highest risk pregnant women to available support services. Please complete the questionnaires and once completed, fax to our Utilization Management Department at 410-433-8500.

Covid-19 Vaccine Administration Fee

Effective November 1, 2021, Jai Medical Systems will reimburse PCPs administering COVID-19 vaccines an enhanced vaccine administration fee of $70.00.

This is a $30.00, or 75% increase, of the current COVID-19 Vaccine Administration rate being paid by Medicaid and Medicare. This enhanced COVID-19 vaccine administration rate will be applicable for dates of service November 1, 2021, through March 31, 2022. Please ensure that when you are billing our organization for the COVID-19 vaccine administration fee that you are billing a rate of $70.00 in order to receive this enhanced reimbursement rate. If your practice is not currently administering COVID-19 vaccines, and you are interested in doing so, please contact our Provider Relations Department today at

Member Satisfaction Survey Results 2020

Jai Medical Systems would like to share with our providers the most recent results of our annual member satisfaction survey. Our member satisfaction survey is an internal survey created by Jai Medical Systems and distributed with the member newsletter annually to receive additional feedback from our members about their experience as a member of our health plan. Based on results that we have received, there are a few areas of member satisfaction that could be improved. Please review the chart below to see the areas where member satisfaction improvement is needed. We appreciate your assistance is helping us improve satisfaction in these important areas.

CAHPS Survey Results

On an annual basis, many Jai Medical Systems’ HealthChoice members have the opportunity to complete a national satisfaction survey called the Consumer Assessment of Healthcare Providers and Systems (CAHPS). The member satisfaction survey results are compared against other MCOs throughout the state and nation. The 2020 CAHPS survey showed that Jai Medical Systems members were very satisfied with How Well their Doctor Communicates. Both adult and child members rated us highly in this composite. We thank all of our participating providers for communicating with your patients so well! Additionally, The adult and child surveys also showed our members were very happy with our Customer Service. We thank you for your continued service to our members.

Formulary Changes/Updates

Effective immediately, the following products have been added to the formulary:
Generic Glucophage XR (please note that the generic versions of Fortamet and Glumetza remain non-formulary)

The following products had a change made to their limitations:

  • Myrbetriq – The PA criteria has been up-dated to include a new diagnosis for use
    • (2) Neurogenic detrusor overactivity
    • (NDO) in pediatric patients
    • For that diagnosis, an additional criteria was also added:
      • Additional Criteria for NDO: aged 3 years and older and weighing 35 kg or more
  • Prandin and Invokana – For both medica-tions the PA criteria has been modified slightly and is now:
    • Diagnosis of Type 2 diabetes mellitus
    • Has not achieved adequate glycemic control on at least ONE of the follow-ing:
      • Metformin (alone or in combina-tion)
      • A Sulfonylurea (alone or in com-bination)
      • A preferred DPP-4 inhibiton
    • Contraindication to metformin, a sulfonylurea, OR a preferred DPP-4 Inhibitor
  • Tretinoin Topical Cream (0.1%, 0.05%, 0.025%) and Gel (0.01%, 0.05%, 0.025%) Te Age Limit has been raised from 21 to 32
  • Hepatitis C Treatment PA Form Update – The PA Form for Hepatitis C treatment has been updated based on an update to the Maryland Medicaid template removing reference to Substance Use Disorder history and will be made available on the website or on request. Older versions of the form will still be accepted as long as the nec- essary information is included with the request.

The following changes have also been made:
Opioid Quantity Limit – Effective November 1, 2021, all members who are new to opioid therapy (defined as there being no fills for an opioid in the previous 90 calendar days) will be limited to no more than 14 day supplies after they have received their initial fill for an opioid; any fills for the initial fill of an opioid will remain limited to no more than a 7 day supply. Prior authorization will be required before an exception can be made for a supply longer than 14 days after the initial fill has been received. All members who are currently receiving opioids (with a fill for more than a 14 day supply in the past 90 days) will be able to continue receiving their current medications without a new prior authorization, unless they stop filling their medication for a gap of 90 days or more. For details about this change, or on how to get a prior authorization, go to and look under Opioid Prescription Policy Changes.

Provider Satisfaction Survey

In order to deliver the best provider experience, it is important that we receive your feedback. Please complete the enclosed Provider Satisfaction Survey. Completed surveys may be returned by fax to 410.433.4615 or by email to

False Claims, Policies and You

The Federal and State False Claims Acts makes it a crime for any person or organization to knowingly present or conceal a false or fraudulent claim for payment to the United States government or to a government contractor, including claims submitted to Medicaid. To comply with the Federal Deficit Reduction Act, we would like to make you aware of your rights and responsibilities under the Federal and State False Claims Acts, administrative remedies, civil penalties, and the protections for whistleblowers under such laws. As an agent, contractor or vendor of Jai Medical Systems Managed Care Organization, Inc., our policies and procedures regarding this legislation not only apply to our employees, it also applies to you.

The criminal penalties for knowingly submitting fraudulent claims could include fines and/or imprisonment. In addition to criminal penalties, administrative remedies can include monetary penalties, costs of the civil action brought to recover any such penalty or damages, plus 3 times the amount of damages which are incurred by the government. These penalties are detailed in 18 U.S.C. Section 287 and 31 U.S.C. Section 3730 of the False Claims Act.

Also, according to the False Claims Act, federal law prohibits retaliation, and as a whistleblower, any employee, contractor, or agent is entitled to all relief necessary to be made whole if they are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against by their efforts to stop a violation.

We welcome and encourage you to report anything suspicious.

Below are a few examples of fraud and abuse:

  • Billing for services that have not been rendered
  • Falsifying a signature on a prescription
  • Duplicate billing
  • Inflating or misrepresenting services, units or procedures provided
  • Billing for services that are not necessary

To report fraud & abuse or if you have any questions regarding our policies and procedures, please contact our Fraud and Abuse Compliance Officer at 1-888-JAI-1999. You can also write to:
Jai Medical Systems
301 International Circle
Hunt Valley, MD 21030

For more information regarding fraud and abuse, please visit our website:

Have you enrolled with ePREP?

Maryland Medicaid requires all providers rendering care to Medicaid beneficiaries enroll with Medicaid’s new electronic Provider Revalidation and Enrollment Portal (ePREP). Maryland’s ePREP system is Medicaid’s one stop shop for provider enrollment, re-enrollment, revalidation, information updates and demographic changes. According to the Maryland Department of Health, all providers submitting claims for HealthChoice members must enroll with ePREP as soon as possible.

Failure to enroll in Maryland Medicaid’s ePREP system and be an active provider will result in claims denials.

To enroll or revalidate with Maryland Medicaid today, please visit the ePREP website at or contact the ePREP call center at 1.844.463.7768.

If you have any questions about the ePREP enrollment process, please feel free to contact our Provider Relations Department today at 1-888-JAI-1999 or the Maryland Department of Health at

Claim Submission Guidelines

To ensure that your claims are processed quickly and accurately, please be sure to follow these simple guidelines regarding billing practices, referrals, and authorizations. When submitting the following type of claim, please ensure that you are following Jai Medical Systems’ Billing Instructions in addition to the listed items below:

  • Timely submit all claims, either electronically or on paper, within 180 days of the date of service.
  • Attach or Fax one copy of a valid completely filled out, legibly written referral, outpatient authorization, or inpatient authorization, where applicable, to Jai Medical Systems’ Claims Processing Center (fax number 1-866-381-7200) prior to claim submission.
  • Include the appropriate authorization number that is valid for the claim being billed. Authorizations include referrals, outpatient authorization, or inpatient authorization to be billed in the appropriate field. This field is located in block 23 for the CMS1500 form and block 63 for the UB-04.
  • Indicate or attach a copy of the member’s primary insurance Explanation of Payment (EOP) or Remittance advice any information regarding the member’s primary insurance and any payment made from the third party payor (TPP), if applicable.

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
  • 24 Hour Nurse Advice Line: Please inform members about our 24 Hour Nurse Advice Line. To access, members should call 1-844-259-8613.
  • Health Risk Assessment: Please encourage members to utilize our new online wellness portal, located at Our wellness portal features wellness tips, health education videos, and a health assessment that members can complete.
  • Online Health Education Health Education materials are available to Jai Medical Systems members online. Members can access these materials by registering on the member portal located at
  • 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 determi-nation letter. Providers have 85 business days to submit a third level appeal from the date that the first level appeal was received.
  • E-Blast! At Jai Medical Systems, we are continually striving to reduce our impact on the environment and improve provider satisfaction. Providers are automatically enrolled to receive emails from Jai Medical Systems. If you would like to opt out, please select the unsubscribe button at the bottom of the email. To sign-up today, please visit our website at

Visit Us Online

There are many services available online to both our members and providers. The resources listed in the chart to the right are available on our provider portal or on our website at

If you prefer, all of this information is also available in print and/or by telephone. You may request this information by calling the Provider Relations Department at today 1-888-JAI-1999.

Contact Us
301 International Circle Hunt Valley, MD 21030
Phone: 1-888-JAI-1999
Hours of Operation: Monday – Friday