Md. Code Regs. 10.09.09.07

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

Section 10.09.09.07 - Payment Procedures

A. General policies for payment procedures that are applicable to all providers are set forth in COMAR 10.09.36.04A.

B. Medical laboratory providers shall identify the individual who ordered the laboratory services by recording the individual practitioner's National Provider Identifier (NPI) number on the claim.

C. Unless the service is free to individuals not covered by Medicaid, the provider shall charge the Program the lesser of.

(1) The provider's customary charge to the general public; or

(2) The provider's customary charge to other third-party payers.

D. Providers are reimbursed according to the 2022 Medical Laboratory Fee Schedule (Effective March 2022). All the provisions of this document are incorporated by reference.

E. The Department will pay for covered services the amount that is the lower of the following:

(1) Provider's charge according to §C of this regulation; or

(2) Department's maximum rates according to §D of this regulation.

F. Payments on Medicare claims are authorized if:

(1) The provider accepts Medicare assignments;

(2) Initial billing is made directly to Medicare according to Medicare guidelines; and

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

G. Supplemental payment on Medicare claims is made subject to the following provisions:

(1) Deductible insurance will be paid in full;

(2) Beginning with August 1, 2010 dates of service, 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, but covered by the Program, will be paid according to §E of this regulation.

H. The provider may not bill the Department for:

(1) Completion of forms and reports;

(2) Broken or missed appointments; or

(3) Services listed in Regulation .05 of this chapter.

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

J. When seeking reimbursement for medical laboratory services which are subjected to panel billing regulations or are part of a panel, the medical laboratory provider shall bill the Department the panel rate or the sum of the charges of the individual tests, whichever is less.

K. A referring laboratory provider may bill the Program for laboratory services performed by a reference laboratory when the:

(1) Reference laboratory is:

(a) Enrolled with the Program as either a medical laboratory provider or a renderer; and

(b) CLIA certified for the procedures performed;

(2) Procedures which were referred, and the identity of the reference laboratory, are identified on the invoice; and

(3) Referring laboratory charges not more than the amount it actually paid the reference laboratory.

L. Standing orders shall:

(1) Conform to the specifications for orders found in Regulations .01 and .04 of this chapter;

(2) Include:

(a) A date which shall become the starting date of the order unless another starting date is specified on the order; and

(b) Specific instructions outlining the schedule of services to be provided pursuant to the order; and

(3) Be effective for a maximum of 90 days or, for dialysis patients, be effective for a maximum of 1 year.

M. All indices, calculated values, or other results that are not directly determined, are considered part of the parent procedures and are not separately billable to either the Program or the participant.

N. Only those panels or profiles that have a composition specified by CPT or the Program are reimbursable as panels or profiles by the Program. Reimbursement for these recognized panels or profiles is not authorized unless each and every component of the panel or profile is performed.

O. Two or more of the following chemistry tests shall be reimbursed at a rate that is the lesser of the provider's lowest charge to the general public or third-party payers, or the Program's maximum reimbursement for these chemistry tests when performed as panels:

(1) Albumin, serum;

(2) Bilirubin, direct;

(3) Bilirubin, total;

(4) Calcium, total;

(5) Carbon dioxide (bicarbonate);

(6) Chloride, blood;

(7) Cholesterol, serum, total;

(8) Creatine kinase (CK), (CPK), total;

(9) Creatinine, blood;

(10) Glucose, quantitative;

(11) Glutamyltransferase, gamma (GGT);

(12) Lactate dehydrogenase (LD), (LDH);

(13) Phosphatase, alkaline;

(14) Phosphorus, inorganic;

(15) Potassium, serum;

(16) Protein, total, except refractometry;

(17) Protein, total, refractometric;

(18) Sodium, serum;

(19) Transferase, aspartate amino (AST) (SGOT);

(20) Transferase, alanine amino (ALT) (SGPT);

(21) Triglycerides;

(22) Urea nitrogen, quantitative (BUN); and

(23) Uric acid, blood.

P. All of the tests listed in §O of this regulation that are ordered on or performed on the same specimen shall be billed as if performed simultaneously.

Md. Code Regs. 10.09.09.07

Regulation .07 amended as an emergency provision effective September 16, 1992 (19:20 Md. R. 1812); amended permanently effective January 1, 1993 (19:25 Md. R. 2205)
Regulation .07B amended effective February 6, 1989 (16:2 Md. R. 159)
Regulation .07D amended effective December 15, 1978 (5:25 Md. R. 1854); February 15, 1982 (9:3 Md. R. 221)
Regulation .07E amended as an emergency provision effective July 1, 1982 (9:13 Md. R. 1347); adopted permanently effective November 1, 1982 (9:21 Md. R. 2106)
Regulation .07E amended as an emergency provision effective July 1, 1984 (11:13 Md. R. 1169); adopted permanently effective October 29, 1984 (11:21 Md. R. 1812)
Regulation .07E amended effective December 6, 1982 (9:24 Md. R. 2390); November 21, 1983 (10:23 Md. R. 2063); May 27, 1984 (11:10 Md. R. 863); 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); June 2, 1986 (13:11 Md. R. 1273); December 1, 1986 (13:22 Md. R. 2398)
Regulation .07E amended as an emergency provision effective July 1, 1986 (13:14 Md. R. 1626); adopted permanently effective October 6, 1986 (13:20 Md. R. 2210)
Regulation .07E amended as an emergency provision effective October 1, 1986 (13:22 Md. R. 2393); emergency status expired February 8, 1987
Regulations .07E repealed and new Regulation .07E adopted effective February 9, 1987 (14:3 Md. R. 273); amended 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)
Regulation .07E 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 .07F amended effective April 9, 1984 (11:7 Md. R. 625)
Regulation .07H amended as an emergency provision effective February 1, 1979 (6:2 Md. R. 71); emergency status extended at 6:12 Md. R. 1045; adopted permanently effective June 1, 1979 (6:11 Md. R. 979)
Regulation .07K 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)
Regulation .07K amended effective January 30, 1984 (11:2 Md. R. 113); September 10, 1984 (11:18 Md. R. 1584)
Regulation .07K 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 .07K 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 .07L adopted effective December 15, 1978 (5:25 Md. R. 1854)
Regulation .07M adopted effective February 6, 1989 (16:2 Md. R. 159)
Regulation .07B, D amended effective April 29, 2002 (29:8 Md. R. 700)
Regulation .07C, D amended effective September 18, 2000 (27:18 Md. R. 1665)
Regulation .07D amended effective December 12, 2011 (38:25 Md. R. 1581)
Regulation .07g amended effective April 4, 2011 (38:7 Md. R. 430)
Regulation .07L-P adopted effective September 18, 2000 (27:18 Md. R. 1665); amended effective 43:13 Md. R. 712, eff.7/4/2016; amended effective 44:4 Md. R. 252, eff. 2/27/2017; amended effective 44:15 Md. R. 759, eff. 7/31/2017; amended effective 44:26 Md. R. 1214, eff. 1/1/2018; amended effective 48:12 Md. R. 472, eff. 6/14/2021; amended effective 50:14 Md. R. 593, eff. 7/24/2023