Division of Health Services
The Johns Hopkins Health Plans Division of Health Services is committed to quality health care, and partnership with our dedicated providers is key to achieving this goal.
The Division of Health Services departments include:
To request an appeal of denied services, refer to the provider appeal rights on the denial letter.
Fax appeals to:
Johns Hopkins Health Plans
Attn: Appeals Department
7231 Parkway Drive, Suite 100
Hanover, MD 21076
Pre-service and medication expedited appeals only may be called in to the expedited verbal appeals phone line: 410-762-5383.
The Johns Hopkins Health Plans Care Management team offers a variety of services to help members manage chronic health conditions, recover from serious illness, and make healthy lifestyle changes. Our care management services are voluntary and are provided at no cost to the member. Members identified with certain needs may be automatically enrolled, but are under no obligation to participate in these programs.
The Care Management team collaborates with members, their family or caregivers and their providers to assist members in learning about their health conditions, navigating their treatment, removing barriers to care and linking members to resources. The Care Management team assists members in developing condition specific self-management skills to stabilize their health. We are here to support all members wherever they are on the health continuum. The Care Management team also provides assistance to all members as they transition from an emergency department visit or inpatient hospitalization to the community (home).
Care Management Services
We can collaborate with you to help your members access a variety of services.
Care Managers provide guidance on timely health screenings, annual well checks, and immunizations, as well as refer members to health education classes and the health library to help members manage their health so they can stay as healthy as possible. Qualified health care professionals will provide assistance to help close gaps in care, which may include: annual wellness visits, screenings, monitoring labs to ensure therapeutic levels of a medication, earlier intervention, and engagement with a health care provider to proactively manage a potential health exacerbation based on clinical indicators (i.e. elevated blood pressure and HbA1c that are not within range).Services include:
- Health maintenance and prevention reminders to promote self-management skills
- Health education
- Recommendations on how to manage and maintain overall health and wellness
Care Managers can provide members with assistance navigating the health care system following a health event such as an emergency department (ED) visit, a recent hospitalization, a new diagnosis or significant life event. Care Managers support members as they transition from the ED or hospital setting to the community (home) to help them obtain appropriate provider follow-up after an ER visit, hospitalization or significant life event, as well as to access the medications or other medical supplies they need to continue their treatment. Care Manager support helps members better manage their health and reduce avoidable re-admissions.Services include:
- Care coordination, including assistance with setting up appointments with providers
- Coordination of durable medical equipment and supplies
- Medication management and reconciliation
- Education to improve understanding of diagnoses
- Assistance with gaps in care
Johns Hopkins Health Plans Health Educators are a wonderful resource for all of our members and providers. Our educators advocate, encourage and teach about healthy lifestyles and living well with a chronic condition. Members in special need of educational efforts are identified and assisted with the education needed to meet their needs.Services can be delivered through the following educational methods:
- Health education classes (synchronous and asynchronous) and activities: view our program descriptions and current class dates and times at the member’s health plan website under Health and Wellness > Health Education.
- Development and distribution of health-related newsletters, fact sheets and brochures.
- Collaboration with Care Managers in providing member education to reinforce member’s treatment plans.
Complex Care Management provides care management services for members with one or more complex medical conditions and over- or under-utilization of health care services. Johns Hopkins Health Plans recognizes that individuals often have two or more health problems that can be well served by evidenced-based care management. Licensed Clinical Social Workers or Registered Nurse Care Managers partner with members and providers to assist adult members in learning about their diagnoses and improving their skills in managing chronic health conditions like asthma, diabetes, cardiovascular conditions, chronic obstructive pulmonary disease, sickle cell, cancer, pain management, Alzheimer's, rehabilitative needs, HIV/AIDS, seizure disorders, developmental disabilities, chronic kidney disease and chronic lung disease. We also partner with members’ parents and/ or caregivers to provide services to children 18 years and younger with chronic conditions such as asthma, diabetes, sickle cell disease, neurological conditions, various genetic syndromes, cancer and morbid obesity, or after an organ transplant.Services include:
- Complex Care Management Assessment completed on all members
- Coordination of transitions of care support services for members in all service areas
- Coordinate care with PCPs, specialists, DME/service providers
- Support self-management
- Address barriers and gaps in care by creating innovative solutions and involving community resources
- Education on signs and symptoms of worsening disease
Maternal - Child Health (MCH) Care Management is available to prenatal and postpartum members, and families with newborns and children. Members partner with a Registered Nurse Care Manager to receive support in connecting to services and resources. We offer health education, community resources, care coordination and promote access to quality health services. We strive to contact and engage with members as soon as possible. With family engagement in goal setting, we improve self-reliance and build confidence in navigating the health care system.
- Pregnancy Support- OB Nurse Care Managers provide pregnancy support to pregnant members with high-risk conditions such as pre-term labor, substance abuse, hypertension, asthma, diabetes or adolescent pregnancy. Social determinants of health are assessed and barriers influencing a member’s engagement in prenatal or postpartum health are addressed. Care managers coordinate the member’s care with OB providers, maternal-fetal medicine and/or other specialists during pregnancy. We encourage member participation in prenatal care, medication management, healthy eating, safe home environment, stress reduction, self-care and improved emotional health. Members remain in care management after delivery expanding the opportunity for member care in the postpartum period.
- Support for infants and children - Pediatric Nurse Care Managers engage with members 18 years and younger with risk factors that include, but are not limited to, conditions such as asthma, diabetes, sickle cell disease, behavioral and neurological disorders, genetic syndromes. A comprehensive assessment assists the Care Manager in identifying needs, barriers and social determinants of health that assist the Care Manager in understanding the health and wellness of the newborn or child. The Care Manager collaborates with multiple providers, home health care, community agencies and the school system, when applicable, to aid in meeting specific physical, psychosocial and emotional needs of the developing child and family across the health care continuum.
Members living with mental health or substance abuse concerns, may receive confidential care management support and coordination of care from a Licensed Clinical Social Worker. These behavioral health clinicians help members navigate their treatment needs for conditions such as depression, anxiety disorders, addictions, and autism spectrum disorders.
Care Management works with the following vendors:
For Advantage MD and Priority Partners members, we work with Evicore to assist members with transitional care after discharge from a skilled nursing facility.
For EHP and Priority Partners members, we work with Progeny Health, LLC. to assist members with utilization management for infants born and admitted to neonatal intensive care units (NICU). Progeny Health, LLC. also offers care management to NICU graduates through their first year of life.
For Priority Partners members, we work with Optum Maryland to manage mental health needs.
Please send us your referrals by contacting us at:
Monday through Friday: 8 a.m. to 5 p.m.
Voicemail messages received after normal business hours will be addressed the following business day.
Email: [email protected]
The aim of the Johns Hopkins Health Plans Utilization Management (UM) program is to achieve the mission of providing access to high quality, cost-effective, member-centered care. Johns Hopkins Health Plans' utilization management decisions are based on appropriate care and existence of coverage.
Johns Hopkins Health Plans does not give financial incentives to staff that reward denials or promote under-utilization of services. Johns Hopkins Health Plans does not make decisions about hiring, promoting, or terminating practitioners or Johns Hopkins Health Plans staff based on the likelihood that the practitioner or Johns Hopkins Health Plans staff member supports denials of benefits. You may request a copy of the UM criteria or benefit guidelines used in the decision of any case. For concurrent inpatient admissions, a UM RN is on-call after hours, including weekends and holidays to assist with urgent admissions and discharge planning.
410-424-4480 or 800-261-2421 (toll-free) Monday through Friday, 8 a.m. to 5 p.m.
Fax #’s for EHP, PPMCO and USFHP
- Inpatient Medical: 410-424-4894
- Outpatient Medical: 410-762-5205
- Initial Inpatient: 410-424-2770
- Transplant/Bariatric: 410-424-4046
- SNF/LTAC/ACIR/AMBO Requests: 410-424-2703
- EHP & PPMCO NICU Admissions or Prior Pediatric Readmission (within 1 year of NICU discharge): fax notification and/or clinical to ProgenyHealth: 888-400-4636
- EHP & PPMCO Outpatient Urgent: 410-424-2707
- EHP & PPMCO Durable Medical Equipment (DME): 410-762-5250
- EHP Behavioral Health: 410-424-4891
- EHP Behavioral Health- Secured: 410-424-4765
- USFHP DME: 410-424-2603
- USFHP Inpatient: 410-424-2602
- USFHP Outpatient: 410-424-2603
- USFHP Behavioral Health: 410-424-4839
- eviCore Healthcare: 866-220-3071
*For DME, search Medical Equipment under Service Type in the Provider Directory.
Advantage MD: 844-560-2856
Advantage MD Behavioral Health, Inpatient & Outpatient: 844-340-2217
Fax #’s for Advantage MD
- Outpatient Medical: 855-704-5296
- Inpatient Medical: 844-240-1864
- Outpatient Behavioral Health: 844-363-6772
- Inpatient Behavioral Health: 844-699-7762
- Post-Acute Facility (SSNF/ACIR/LTAC): 410-424-2703
*For DME, search Medical Equipment under Service Type in the Provider Directory.