Md. Code Regs. 10.09.01.06

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.01.06 - Payment Procedures

A. The provider shall submit the re quest for payment in the format designated by the Department.

B. The Department reserves the right to return to the provider, before payment, all requests for payment not properly completed.

C. The provider shall charge the Program the provider's:

(1) Customary charge to the general public for similar services; and

(2) Acquisition cost for injectable drugs or dispensed medical supplies.

D. The provider shall be paid the lesser of:

(1) The provider's customary charge to the general public unless the service is free to individuals not covered by the Program; or

(2) The Program rates as described in COMAR 10.09.02.07.

E. If a service is free to individuals not covered by the Program:

(1) The provider:

(a) May charge the Program; and

(b) Shall be reimbursed in accordance with §D of this regulation; and

(2) The provider's reimbursement is not limited to the provider's customary charge.

F. Payments on Medicare claims are authorized, if:

(1) Services are covered by the Program;

(2) The provider accepts Medicare assignments;

(3) Medicare makes direct payment to the provider;

(4) Medicare has determined that services were medically justified; and

(5) Initial billing is made directly to Medicare according to Medicare guidelines.

G. The Department shall make supplemental payments on Medicare claims subject to the following provisions:

(1) Deductible insurance shall be paid in full; and

(2) Coinsurance shall be paid at the lesser of:

(a) 100 percent of the coinsurance amount; or

(b) The balance remaining after the Medicare payment is subtracted from the Program rate.

H. The provider may not bill the Program for:

(1) Completion of forms and reports;

(2) Broken or missed appointments; or

(3) Professional services rendered by mail.

I. The Program may not make direct payment to participants.

J. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.

K. The Program shall reimburse for all medical laboratory services according to the fees established under COMAR 10.09.09.

L. An advanced practice nurse who is employed by or under contract to any physician, clinic, or hospital may not bill for any service for which reimbursement is sought by the physician, clinic, or hospital.

M. The Program may not reimburse nurse midwives for prenatal or postpartum care once the patient has been referred to a physician for completion of prenatal or postpartum care.

Md. Code Regs. 10.09.01.06

Regulation .06 amended as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004)
Regulation .06 amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004)
Regulation .06E amended effective May 31, 1999 (26:11 Md. R. 854)
Regulation .06F amended effective April 4, 2011 (38:7 Md. R. 430)
Regulation .06K adopted effective May 31, 1999 (26:11 Md. R. 854)
Regulation .06B amended as an emergency provision effective January 1, 1978 (5:1 Md. R. 14); adopted permanently effective May 5, 1978 (5:9 Md. R. 683)
Regulation .06B amended effective July 1, 1978 (5:13 Md. R. 1051)
Regulation .06B amended as an emergency provision effective July 2, 1979 (6:14 Md. R. 1202); adopted permanently effective November 2, 1979 (6:22 Md. R. 1779)
Regulation .06B amended effective July 1, 1980 (7:13 Md. R. 1278)
Regulation .06B amended as an emergency provision effective July 1, 1982 (9:13 Md. R. 1346); adopted permanently effective November 1, 1982 (9:19 Md. R. 1894); amended effective 43:13 Md. R. 712, eff. 7/4/2016; amended effective 44:17 Md. R. 834, eff. 8/28/2017; amended effective 50:16 Md. R. 725, eff. 8/21/2023