Md. Code Regs. 10.09.15.07

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

Section 10.09.15.07 - Payment Procedures

A. The provider shall submit his request for payment on the form designated by the Department including all required documentation.

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

C. The provider shall bill the provider's customary fees, but may not bill a fee in excess of that charged the general public for similar services, except for injectable drugs and dispensed medical supplies, in which case the provider shall charge the Program the provider's acquisition cost. 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 Program shall pay for medically necessary covered services at the lower of the provider's amount billed to the Program or the maximum reimbursement rates set forth in COMAR 10.09.02.07D.

E. Payments on Medicare claims are authorized if:

(1) The 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.

F. Supplemental payment on Medicare claims are made subject to the limitations of the State budget and 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 by the Program, according to §E above.

G. 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;

(4) Laboratory or X-ray services not performed by the provider or under the direct supervision of the provider; or

(5) Photocopying of medical records when requested by another licensed provider on behalf of the participant.

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

I. The Program shall reimburse providers for all laboratory services according to the fees established under COMAR 10.09.09.07A and for all radiological services under COMAR 10.09.02.07A.

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

Md. Code Regs. 10.09.15.07

Regulation .07C amended effective September 19, 1980 (7:19 Md. R. 1806)
Regulation .07D 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 .07D amended as an emergency provision effective July 1, 1984 (11:13 Md. R. 1170); adopted permanently effective October 29, 1984 (11:21 Md. R. 1813)
Regulation .07D amended effective March 11, 1985 (12:5 Md. R. 482)
Regulation .07D amended as an emergency provision effective October 1, 1986 (13:22 Md. R. 2393); adopted permanently effective February 9, 1987 (14:2 Md. R. 129)
Regulation .07D amended effective February 24, 1997 (24:4 Md. R. 291); June 14, 1999 (26:12 Md. R. 925); June 24, 2002 (29:12 Md. R. 927); August 27, 2007 (34:17 Md. R. 1507)
Regulation .07E amended effective April 9, 1984 (11:7 Md. R. 625)
Regulation .07G amended as an emergency provision effective January 8, 1979 (6:2 Md. R. 72); emergency status extended at 6:12 Md. R. 1045; adopted permanently effective June 1, 1979 (6:11 Md. R. 979)
Regulation .07G amended effective April 4, 2011 (38:7 Md. R. 430)
Regulation .07H amended effective June 14, 1999 (26:12 Md. R. 925); January 2, 2006 (32:26 Md. R. 1997)
Regulation .07J amended effective June 14, 1999 (26:12 Md. R. 925)
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. 1984)
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); amended effective 43:13 Md. R. 712, eff.7/4/2016; amended effective 44:4 Md. R. 252, eff. 2/27/2017; amended effective 45:14 Md. R. 696, eff. 7/16/2018; amended effective 50:16 Md. R. 725, eff. 8/21/2023