Md. Code Regs. 10.09.02.07

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

Section 10.09.02.07 - Payment Procedures

A. The provider shall submit the request for payment on the form designated by the Department.

B. The Department reserves the right to return to the provider, before payment, all invoices not properly signed, completed, and accompanied by properly completed forms required by the Department.

C. Except as provided in §F of this regulation, the Provider shall charge the Program the provider's customary charge to the general public for similar services. If the service is free to individuals not covered by Medicaid:

(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.

D. The Maryland Medical Assistance Program's procedures for payment are contained in the following documents, the provisions of which are incorporated by reference:

(1) The Professional Services Provider Manual and Fee Schedule (Effective January 2023); and

(2) The Medical Laboratories Fee Schedule pursuant to COMAR 10.09.09.07D.

E. Except as provided in §F of this regulation, the Department will pay for covered services at the lesser of:

(1) Physician's customary charge or acquisition cost unless the service is free to individuals not covered by Medicaid, or

(2) The Department's fees in accordance with §D of this regulation.

F. The Program shall reimburse providers up to the acquisition cost for diagnostic and therapeutic radiopharmaceuticals, contraceptive products and devices, and injectable medications when the provider submits documentation indicating that the acquisition cost of the product, device, or drug is greater than the reimbursement allowed in §E of this regulation.

G. The Program reserves the right to negotiate and establish a different fee for a physician or a group of physicians under contract to a hospital to provide services when a portion of the cost of the contract is paid as the hospital's cost, provided this fee does not exceed limitations set forth in §E of this regulation.

H. Supplemental payments on Medicare claims are made subject to the following provisions:

(1) Deductible insurance will be paid in full;

(2) Beginning with August 1, 2010 dates of service, and subject to the limitations of the State budget, coinsurance, shall be paid:

(a) In full for the following:

(i) Mental health services;

(ii) CPT codes that are priced by report;

(iii) Claims for anesthesia services;

(iv) Claims from a federally qualified health center; and

(v) HCPCS codes beginning with A through W; and

(b) For all other claims, at the lesser of:

(i) 100 percent of the coinsurance amount; or

(ii) The balance remaining after the Medicare payment is subtracted from the Medicaid rate; and

(3) Services not covered by Medicare are payable according to §E of this regulation.

I. Payments on Medicare claims are authorized if the:

(1) Provider accepts Medicare assignments;

(2) Medicare makes direct payment to the provider;

(3) Medicare has determined that services were medically justified;

(4) Services are covered by the Program;

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

J. The provider may not bill the Department or the participant for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Professional services rendered by mail; or

(4) Providing a copy of a participant's medical record when requested by another licensed provider on behalf of the participant.

K. The Program will make no direct payment to participants.

L. The Program will reimburse the provider for dispensed drugs at rates established in COMAR 10.09.03. The provider shall bill the Program in accordance with COMAR 10.09.03 using the Pharmacy Invoice.

M. The Program will reimburse the provider for dispensed medical supplies at actual cost or at rates established by COMAR 10.09.12, whichever is less.

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

O. Providers shall bill the Program in the following manner:

(1) A physician whose laboratory is not required to be registered pursuant to Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, shall bill the Program for laboratory services in accordance with procedures required under these regulations;

(2) A physician whose laboratory is registered as a medical laboratory pursuant to Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, shall bill the Program for laboratory services in accordance with procedures required under COMAR 10.09.09.

P. Reimbursement.

(1) The Program shall reimburse providers for all laboratory and other diagnostic services performed by a physician, or by authorized personnel under that physician's supervision, for that physician's patients.

(2) Reimbursement shall be according to all applicable provisions of COMAR 10.10.06 and fees established according to §D of this regulation.

(3) Maximum reimbursement may not exceed the Medicare laboratory fee established by the Maryland Medicare carrier recognized by the Program.

(4) The Program shall reimburse providers for mental health services performed by a physician according to the fees established under COMAR 10.21.25 and the requirements of this chapter.

Md. Code Regs. 10.09.02.07

Existing regulations repealed and new Regulations .07 adopted effective December 8, 1976 (3:25 Md. R. 1467)
Regulation .07 amended effective December 15, 1978 (5:25 Md. R. 1854)
Regulation .07G amended as an emergency provision effective February 1, 1979 (6:2 Md. R. 71); emergency status extended until June 1, 1979 (6:12 Md. R. 1045); adopted permanently effective June 1, 1979 (6:11 Md. R. 979)
Regulation .07I amended effective April 6, 1979 (6:7 Md. R. 676); repealed effective July 1, 1979 (6:13 Md. R. 1126)
Regulation .07N amended as an emergency provision effective July 1, 1978 (5:14 Md. R. 1131); adopted permanently effective November 3, 1978 (5:22 Md. R. 1673)
Regulations.07 amended effective July 1, 1979 (6:13 Md. R. 1126)
Regulation .07 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 .07 amended as an emergency provision effective July 15, 1992 (19:16 Md. R. 1467); amended permanently effective November 1, 1992 (19:21 Md. R. 1890)
Regulation .07 amended effective March 6, 2000 (27:4 Md. R. 453)
Regulation .07 amended as an emergency provision effective December 18, 2003 (31:2 Md. R. 81); amended permanently effective April 26, 2004 (31:8 Md. R. 646)
Regulation .07C amended effective December 16, 1996 (23:25 Md. R. 1785)
Regulation .07D amended as an emergency provision effective July 1, 1982 (9:13 Md. R. 1347); amended permanently effective November 1, 1982 (9:21 Md. R. 2106)
Regulation .07D amended effective December 6, 1982 (9:24 Md. R. 2390); May 1, 1983 (10:8 Md. R. 725); November 21, 1983 (10:23 Md. R. 2063)
Regulation .07D amended as an emergency provision effective January 27, 1984 (11:4 Md. R. 312); emergency status expired May 26, 1984
Regulation .07D amended effective May 27, 1984 (11:10 Md. R. 863)
Regulation .07D amended as an emergency provision effective July 1, 1984 (11:13 Md. R. 1169); adopted permanently effective October 29, 1984 (11:21 Md. R. 1811)
Regulation .07D amended effective March 11, 1985 (12:5 Md. R. 482); July 15, 1985 (12:14 Md. R. 1432); August 12, 1985 (12:16 Md. R. 1606); March 10, 1986 (13:5 Md. R. 542)
Regulation .07D amended as an emergency provision effective March 1, 1986 (13:6 Md. R. 668); emergency status expired June 30, 1986
Regulation .07D amended effective June 2, 1986 (13:11 Md. R. 1273);
Regulation .07D amended as an emergency provision effective July 1, 1986 (13:12 Md. R. 1371); amended permanently effective December 1, 1986 (13:18 Md. R. 2020)
Regulation .07D amended as an emergency provision effective July 1, 1986 (13:14 Md. R. 1626); amended permanently effective October 6, 1986 (13:20 Md. R. 2210)
Regulation .07D amended as an emergency provision effective October 1, 1986 (13:22 Md. R. 2393); emergency status expired February 8, 1987
Regulation .07D amended effective December 1, 1986 (13:22 Md. R. 2398)
Regulations Regulation .07D repealed and new .07 effective February 9, 1987 (14:3 Md. R. 273); amended effective October 5, 1987 (14:20 Md. R. 2142); February 22, 1988 (15:4 Md. R. 473); July 11, 1988 (15:14 Md. R. 1654); July 25, 1988 (15:14 Md. R. 1654); December 12, 1988 (15:25 Md. R. 2903); January 1, 1989 (15:26 Md. R. 2983); July 1, 1989 (16:12 Md. R. 1335)
Regulation .07D amended as an emergency provision effective September 8, 1989 (16:20 Md. R. 2178); adopted permanently effective January 1, 1990 (16:25 Md. R. 2710)
Regulation .07D amended as an emergency provision effective March 15, 1990 (17:7 Md. R. 843); emergency status expired June 30, 1990; amended permanently effective July 9, 1990 (17:13 Md. R. 1611)
Regulation .07D amended as an emergency provision effective July 1, 1990 (17:15 Md. R. 1850); amended permanently effective November 1, 1990 (17:20 Md. R. 2427)
Regulation .07D amended effective December 9, 1991 (18:24 Md. R. 2643)
Regulations .07 as an emergency provision effective October 26, 1993 (20:23 Md. R. 1799); emergency status extended at 20:24 Md. R. 1863 and 21:11 Md. R. 949; emergency status expired July 4, 1994
Regulation .07D amended effective July 4, 1994 (21:13 Md. R. 1156)
Regulation .07D amended as an emergency provision effective December 1, 1994 (21:26 Md. R. 2183); emergency status expired April 30, 1995
Regulation .07D amended as an emergency provision effective February 3, 1995 (22:4 Md. R. 231); emergency status expired May 31, 1995; adopted permanently effective August 14, 1995 (22:16 Md. R. 1221)
Regulation .07D amended effective December 16, 1996 (23:25 Md. R. 1785); December 29, 1997 (24:26 Md. R. 1757)
Regulation .07D amended effective February 5, 2001 (28:2 Md. R. 99)
Regulation .07D amended as an emergency provision effective July 1, 2002 (29:14 Md. R. 1073); amended permanently effective September 16, 2002 (29:18 Md. R. 1443)
Regulation .07D amended as an emergency provision effective July 1, 2005 (32:17 Md. R. 1437); amended permanently effective October 24, 2005 (32:21 Md. R. 1707)
Regulation .07D amended as an emergency provision effective July 1, 2006 (33:15 Md. R. 1273); amended permanently effective September 11, 2006 (33:18 Md. R. 1505)
Regulation .07D amended as an emergency provision effective July 1, 2007 (34:13 Md. R. 1149); amended permanently effective August 27, 2007 (34:17 Md. R. 1507)
Regulation .07D amended as an emergency provision effective July 1, 2008 (35:17 Md. R. 1480); amended permanently effective October 6, 2008 (35:20 Md. R. 1774)
Regulation .07D amended effective November 16, 2009 (36:23 Md. R. 1817); November 14, 2011 (38:23 Md. R. 1421); October 28, 2013 (40:21 Md. R. 1775)
Regulation .07E amended effective April 9, 1984 (11:7 Md. R. 625)
Regulation .07G amended effective April 4, 2011 (38:7 Md. R. 430)
Regulation .07O amended effective January 30, 1984 (11:2 Md. R. 113); September 10, 1984 (11:18 Md. R. 1584)
Regulation .07O 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 .07J, M, N amended effective December 12, 1988 (15:25 Md. R. 2902)
Regulation .07Q amended as an emergency provision effective March 15, 1990 (17:7 Md. R. 843); emergency status expired June 30, 1990; amended permanently effective July 9, 1990 (17:13 Md. R. 1611)
Regulation .07Q amended effective December 29, 1997 (24:26 Md. R. 1757)
Regulation .07R adopted effective October 1, 1985 (12:19 Md. R. 1848)
Regulation .07S adopted effective December 16, 1996 (23:25 Md. R. 1785)
Regulation .07 amended effective 41:25 Md. R. 1478, eff.12/22/2014; amended effective 43:13 Md. R. 712, eff.7/4/2016; amended effective 44:4 Md. R. 252, eff. 2/27/2017; amended effective 44:17 Md. R. 834, eff. 8/28/2017; amended effective 45:17 Md. R. 803, eff. 8/27/2018; amended effective 45:26 Md. R. 1241, eff. 12/31/2018; amended effective 46:20 Md. R. 843, eff. 10/7/2019; amended effective 48:12 Md. R. 470, eff. 6/14/2021; amended effective 50:13 Md. R. 512, eff. 7/10/2023; amended effective 51:12 Md. R. 618, eff. 6/24/2024.