Md. Code Regs. 10.09.17.06

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

Section 10.09.17.06 - Payment Procedures

A. The provider shall submit the request for payment of services rendered according to procedures established by the Department and in the format designated by the Department.

B. The provider shall certify on the invoice that the treatment order is on file and was in effect at the time that services were rendered.

C. The provider shall specify on the invoice the type of treatment provided.

D. A provider shall bill the Program the provider's customary charge. 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 the rate provisions of §E of this regulation; and

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

E. The services covered in this chapter are reimbursed according to COMAR 10.09.23.01-1.

F. The Department will pay for covered services, the lesser of:

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

(2) The Department's fee schedule.

G. Supplemental payment on Medicare claims for patients is 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 covered by the Program, according to §F, in this regulation.

H. Payments on Medicare claims are authorized if:

(1) The provider accepts Medicare assignment;

(2) Medicare makes direct payment to the provider;

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

(4) Services are covered by the Program; and

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

I. The provider may not bill the Department for:

(1) Services rendered by mail or telephone;

(2) Completion of forms and reports; or

(3) Broken or missed appointments.

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

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

Md. Code Regs. 10.09.17.06

Regulation .06E amended effective November 14, 2011 (38:23 Md. R. 1421)
Regulation .06G amended effective April 4, 2011 (38:7 Md. R. 430); amended effective 43:13 Md. R. 712, eff.7/4/2016; amended effective 44:4 Md. R. 253, eff. 2/27/2017; amended effective 45:17 Md. R. 803, eff. 8/27/2018