In This Section      


Coronavirus (COVID-19) Prevention and Coverage Information for Plan Members

To address concerns about coronavirus (COVID-19), Johns Hopkins HealthCare posted important information on member websites. This messaging covers the COVID-19 virus, how the virus is spread, and actions members can take to protect themselves and their families. We have also assured them that any COVID-19 testing or treatment they need will be covered by their health plans and that they would pay their usual cost shares. We reminded members about these steps they can take to prevent infection:

  • Wash your hands often with soap and water for at least 20 seconds, especially:
    • Before eating
    • After going to the bathroom
    • After blowing your nose, coughing, or sneezing
  • When you can’t get to soap and water, use a hand sanitizer with at least 60% alcohol.
  • Stay home when you are sick.
  • Avoid close contact with people who are sick. If someone is sick at home, wash your hands before and after caring for them.
  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

We directed members to the CDC’s COVID-2019 website to keep up with the latest updates. We also instructed them to call their providers if they develop coronavirus symptoms—fever, cough, or trouble breathing—if they have been in close contact with someone who has COVID-19, or believe they may have been exposed to the virus.

The CDC and Johns Hopkins Medicine are sources for the latest information about the virus.

Address Changes for Johns Hopkins HealthCare

Effective April 15, 2019, Johns Hopkins HealthCare will have a new address. This will also affect our health plans: Johns Hopkins Advantage MD (PPO and HMO), Johns Hopkins Employer Health Programs (EHP), Priority Partners, and Johns Hopkins US Family Health Plan (USFHP). We are now located at:
7231 Parkway Dr.
Suite 100
Hanover, MD 21076

Until May 3, for express and courier deliveries, please use our current address:
6704 Curtis Court
Glen Burnie, MD 21060

After May 3, please use our new address for all deliveries.

When sending paper claims to JHHC, please use the address on the back of the member’s ID card. All mail will be forwarded to the correct address until new member ID cards are issued.

Thank you for your cooperation.

Revised Procedure for Criminal Background Checks for Prospective USFHP Providers

JHHC is required to initiate criminal background checks, per TRICARE regulations, on initial providers that request to participate with the Johns Hopkins US Family Health Plan (USFHP).

HireRight is a company JHHC utilizes to conduct the criminal background checks. JHHC will initiate the process by submitting to HireRight the email address listed on the provider’s credentialing application.

  • The applicant will receive an email from HireRight containing the web address and login information to fill out the background screening information necessary to complete the background check. Please be advised that a secure online portal is used for the applicant to provide their personal information.
  • Once the applicant signs in using the authentication information provided in the email, they will be required to set up their own password. Instructions will be provided with a brief explanation of what to expect when completing the required information.
  • The applicant will be prompted to provide information appropriate to the screening order (JHHC Criminal Background Check Package). Once complete, the applicant will review the accuracy of the information they entered and then provide an electronic consent.
  • The applicant will review the disclosure and authorization forms, check the two certification boxes and provide an electronic signature.
  • A confirmation message will display an estimated date of completion for the background check.

Provider Pulse

The Winter 2019 issue of "Provider Pulse" is now available online. The issue contains updates on claims and billing, reimbursement reminders and updates, benefits and plan changes and more.

Allergy Copay Issue

JHHC has recently discovered that the $30 copay for allergy shots was not being applied as the member’s liability for claims processed during the 2018 year. The copayment was being paid by the Health plan and rolled into the provider’s total claim payment. This issue has since been corrected and claims processed in 2019 will reflect the correct $30 member liability for these procedures. 

Members affected by this issue will receive mailing informing them of the inconsistent copays and reminding them that specialty office visits require a $30 copay to be paid to the provider. 

Provider Enrollment Portal - ePREP

The Maryland Department of Health (MDH) launched a new electronic Provider Revalidation and Enrollment Portal (ePREP). Implementation of ePREP is to ensure providers are compliant with Federal and State managed care regulations supporting network adequacy, provider information and directory standards, interoperability, information system management, and data reporting. Providers will need to use this portal for Maryland Medicaid and Managed Care Organization (MCO) network enrollment, re-enrollment, revalidation, information updates, and demographic changes.

The ePREP implementation consists of two phases:

Phase I
The first phase will consist of rendering only providers, group practices, and most solo practitioners. A complete list of Phase 1 provider types can be found here. To access Maryland Medicaid’s ePREP visit

To speak to a representative regarding Phase I contact the Call Center at1-844-4MD-PROV (1-844-463-7768)

Phase II
The second phase is scheduled to go live in the Spring of 2018 to include hospitals, clinics, other medical facilities, long-term services and support waivers providers. For questions pertaining to provider enrollment contact the Maryland Department of Health:

Additional Information can be found online at

Priority Partners Policy Changes for Opioid Prescribing

Effective July 1, 2017: The Department of Health and Mental Hygiene (DHMH), Priority Partners (PPMCO) and seven other Medicaid Managed Care Organizations (MCOs) in the Maryland’s HealthChoice Program will implement several policy changes pertaining to opioid prescribing. These policy changes are being made in light of the increasing number of opioid-related deaths occurring in Maryland and amongst Maryland Medicaid beneficiaries. These policies promote changes in prescribing practices based on recent guidance from the Centers for Disease Control (CDC) on Opioid Prescribing for Chronic Pain.

The following changes will be made to prescription opioid coverage for Priority Partners.

Prior authorization will be required for:

  • All formulary long-acting opioids such as:
    • Morphine extended release (MS contin®)
    • Oxymorphone extended release
    • Fentanyl transdermal patches (Duragesic®)
    • Methadone for pain (Dolophine®)
  • Any opioid prescription (or combination of opioid prescriptions) that results in a patient exceeding 90 morphine milliequivalents (MME) per day. See the instructions on how to calculate MME.
  • Any non-formulary long-acting or immediate release opioids

Outreach activities by DHMH & PPMCO include provider notifications, member notifications, webinars for providers & hospitals, notifications to various prescriber associations, outreach to local entities and many related organizations.


To request a prior authorization, please use the PPMCO Pharmacy Opioid Prior Authorization Request form.

For more information, visit the DHMH Opioid DUR website. For questions about Maryland Medicaid's Opioid Drug Utilization Review Workgroup or any of our resources, please contact

Tier Changes to TRICARE Formulary Drugs

The Department of Defense Pharmacy &Therapeutics (DoD P&T) Committee oversees the TRICARE Management Activity drug formulary. The DoD P&T has recommended changes to certain prescription drugs that will move them to the non-formulary level (Tier 3) or will require prior-authorization.

Please be mindful that the step-therapy requirement for Nexium is applicable to members new to therapy and those currently on therapy.  Members new to therapy and currently on therapy are required to try formulary drugs, however, you may submit a prior-authorization request if your patient meets any of the following criteria:

  • Use of ALL formulary agents is contraindicated
  • Patient has experienced significant adverse effects from ALL formulary agents
  • All formulary agents result in therapeutic failure

Review the affected drugs and list of changes made to the pharmacy formulary.

For more information or if you have questions, please contact Customer Service at 1-800-808-7347.

Johns Hopkins Advantage MD Pre-Authorization Guidelines Update

Based on your feedback, we have updated the pre-authorization guidelines for the Johns Hopkins Advantage MD programs. The updates are in alignment with industry standard and will be effective April 15.

Summary of updates:

Effective April 15, 2017, the following procedures no longer need pre-authorization:

  • Carpal Tunnel Surgical Decompression
  • Routine Outpatient Mental Health Services
  • Sleep Studies
  • Sacroiliac Joint Injections
  • Transformaminal Epidurals
  • Wound Clinic

Effective April 15, the following procedures have revised pre-authorization requirements:

  • CT – CTA of Heart only
  • MRI – Breast only
  • Outpatient Surgery* (Ambulatory Surgical Center or Hospital-based)

*Specified surgeries continue to have pre-authorization requirements.

Emergency Room Facility Update

Effective March 23, 2017, EHP will follow the ER sudden and serious auto pay list for facility emergency services for members covered under the EHP medical plans for Johns Hopkins Hospital, Johns Hopkins Bayview and Johns Hopkins Health System with group numbers: E00090, E00091, E00092, E00093, E00190, E00192, E00194, E00198, E00006, E00007.

The ER sudden and serious list includes the ICD-10 codes designating an emergency room visit requiring immediate medical attention. The ER sudden and serious list will automatically adjudicate the hospital claims.

Diagnoses listed on the ER sudden and serious list will automatically adjudicate based on the principal diagnosis submitted and billed. This applies for hospitals billing with revenue codes 451/452.

Emergency services claims in which the principal diagnosis is not on the ER sudden and serious list will be subject to medical record review and possible denial of payment for services by EHP.

Please refer to the Emergency Department Review Process, Policy: APL.009 for additional information.

If you have questions or need assistance with any other item, please contact Provider Relations at (888)-895-4998.

Johns Hopkins Advantage MD Influenza "Flu" Vaccinations

People 65 years and older are at greater risk of serious influenza (flu) disease. Immunosenescence (decline in immune function) is a normal part of aging, increasing the susceptibility of flu-related hospitalizations and deaths among people in this age group. We strongly encourage our seniors and their caregivers to get their flu vaccinations during this season.

According to the Centers for Disease Control and Prevention, there are two vaccines designed specifically for people 65 and older:

  • The “high-dose vaccine” is designed specifically for people 65 and older and contains four times the amount of antigen as the regular flu shot. It is associated with a stronger immune response following vaccination (higher antibody production). Results from a clinical trial of more than 30,000 participants showed that adults 65 years and older who received the high dose vaccine had 24% fewer influenza infections as compared to those who received the standard dose flu vaccine. The high dose vaccine has been approved for use in the United States since 2009.
  • The adjuvanted flu vaccine, Fluad, is made with MF59 adjuvant, which is designed to help create a stronger immune response to vaccination. In a Canadian observational study of 282 persons aged 65 years and older conducted during the 2011-12 season, Fluad was 63% more effective than regular-dose unadjuvanted flu shots. There are no randomized studies comparing Fluad with Fluzone High-Dose. This vaccine will be available for the first time in the United States during the 2016-2017 season.

The high-dose and adjuvanted flu vaccines may result in more of the mild side effects that can occur with standard-dose seasonal shots. Mild side effects can include pain, redness or swelling at the injection site, headache, muscle ache, and malaise.

In addition, it is important that people 65 years and older are up to date with pneumococcal vaccination to protect against pneumococcal disease, such as pneumonia, meningitis, and bloodstream infections.   The annual focus on influenza vaccination is an ideal time to ensure that your patients are also up to date on their pneumococcal vaccination.

Johns Hopkins HealthCare (JHHC) will reimburse providers who administer pneumococcal and flu vaccinations for Advantage MD members.

  • Pneumococcal and influenza (flu) virus vaccines are covered by Medicare Part B
  • Member may receive the vaccine at a participating network pharmacy or at the provider’s office
  • Member’s responsibility is $0

The provider must bill the appropriate CPT code, which includes the vaccine and administration of the vaccine, to be reimbursed for this service.

If an Evaluation and Management code (E&M code) is billed with the flu vaccine, it implies an examination has been completed and the applicable copay will be applied.

If you have questions, please contact the JHHC Provider Relations department at 888-895-4998. 

Removal of Quantitative Treatment Limitations for Mental Health and Substance Abuse

Consistent with current standards of practice in mental health and addiction medicine, these changes will reduce administrative barriers and improve access for mental health and substance use disorder treatment.

The following services no longer have quantitative limits, however all other requirements remain unchanged:

  • Partial hospitalization and intensice outpatient programs (must still be pre-authorized and reviewed for medical necessity)
  • Substance use disorder rehabilitation facility (must still be pre-authorized and reviewed for medical necessity)
  • Outpatient individual, family, and group psychotherapy (8 yearly unmanaged visits before submission of a treatment plan is required; outpatient services performed in a hospital or facility setting require referral)
  • Psychological testing (must still be pre-authorized and reviewed for medical necessity)
  • Smoking cessation quit attempts
  • Smoking cessation counseling sessions per attempt

As a result of these changes, mental health and substance use disorder services, regardless of the length or quantity, may be covered as long as the care is authorized and considered medically or psychologically necessary and appropriate. The current benefit of not requiring a referral or authorization for the first eight outpatient mental health visits in a fiscal year remains unchanged.

Also effective October 3, 2016, copays for mental health and substance abuse services will be changed as follows:

 Prior to 10/3/16     On and after 10/3/16
Individual Outpatient Psychotherapy      $25$12/visit
Group Therapy$17$12/visit
Inpatient Mental Health$40/day$11/day ($25 minimum per visit)
Partial Hospitalization$40/day$12/visit

Download the Uniform Treatment Plan form to be submitted for purposes of treatment authorization.

Please contact the customer service department at 410-424-4528 or 800-808-7347 with questions.

NCQA Ratings for 2016-2017

Did you know that NCQA rates the Johns Hopkins Health Plans each year?  All of the John’s Hopkins health plans rated as high performance plans in 2016. NCQA’s Health Insurance Plan Ratings are  based on quality measures (HEDIS), member satisfaction (CAHPS) and NCQA Accreditation standards scores.  NCQA’s uses a rating methodology which classifies plans into scores from 1-5 in 0.5 increments–-a system similar to CMS’ Five-Star Quality Rating System. You can view each plan’s report card on the NCQA website.

The 2016 NCQA ratings are as follows:

  • EHP – High performance (4.0) with Accredited Accreditation
  • PPMCO – High performance (4.0) with Commendable Accreditation
  • USFHP – High Performance (5.0) with Excellent Accreditation

New Resource for EPSDT Requirements

The Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) features many required health care services for children on Medicaid. To help you stay informed about the requirements of EPSDT, we have created a webpage with helpful information and links to periodicity schedules, immunization recommendations, and additional resources. Visit the EPSDT webpage for more information.

Thank you for providing great health care to our Priority Partners child members, and we hope this information helps you to continue this great care.