Effective Date: Oct. 1, 2026

Health Plans Affected: Advantage MD, Employer Health Programs (EHP), Priority Partners, US Family Health Plan (USFHP) 

Type of Change: Regulatory Requirement

Explanation of Change:

Participating providers must meet and maintain Johns Hopkins Health Plans’ credentialing standards. Participating provider groups are responsible for ensuring new practitioners submit a credentialing application to be added to their Participating Agreement with Johns Hopkins Health Plans.  

Starting Oct. 1, 2026, claims will be automatically denied if the rendering practitioner does not have an active credentialing application on file with us. 

By enforcing this process, we are better aligned with existing regulatory rules around credentialing standards.

Claims Business Rule Process

• In the event a new practitioner /provider joins a participating group, the participating group is required under their Agreement to notify Johns Hopkins Health Plans.
  
• The participating group must ensure that a credentialing application to add that practitioner/provider is submitted to Johns Hopkins Health Plans.
  
• Once an application is submitted and accepted by us, practitioners/provider applicants are added to the existing participating group for a provisional period while we conduct the credentialing process. 
  • The Johns Hopkins Health Plans Provider Credentialing department has 120 days to complete credentialing. During the provisional period, claims submitted for covered services provided to members will be processed at the group’s participating rate. 
    NOTE: In the case of a primary care group, we will not assign a panel for member assignment until credentialing is completed and approved. 
• In the event a new practitioner is not approved by the our Special Credentialing Review Committee, it is the responsibility of the participating provider group to ensure that only approved practitioners or providers provide care services to Johns Hopkins Health Plans members.  
• Following the provisional approval period, we may deny claims submitted by a participating provider group if the rendering practitioner’s application has been denied by the Special Credentialing Review Committee or if the rendering practitioner’s credentialing status has expired.

Definitions

• Participating providers are defined as those providers that are both contracted and credentialed with Johns Hopkins Health Plans.

References

1. Maryland Insurance Administration
2. Maryland Code 15-112(w)