Md. Code Regs. 10.09.36.03

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.36.03 - Conditions for Participation

A. To participate in the Program, the provider shall:

(1) Ensure compliance with all the Medical Assistance provisions listed in the Code of Maryland Regulations (COMAR) designated for their provider type;

(2) Apply for participation in the Program using the application form designated by the Department;

(3) Be approved for participation by the Department;

(4) Allow the Department or its agents to conduct unannounced on-site inspections of any and all provider locations;

(5) Allow the Department or its agents to require all providers to consent to criminal background checks, including fingerprinting;

(6) Have a current provider agreement with the Program in effect and fully comply with the terms and conditions stated in the provider agreement;

(7) Comply with all standards of practice, professional standards and levels of service as set forth in all applicable federal and State laws, statues, rules, and regulations as well as all administrative policies, procedures, transmittals, and guidelines issued by the Department;

(8) Charge the Program the provider's customary charge to the general public for similar items or services. If the item or service is free to individuals not covered by Medicaid:

(a) The provider:

(i) May charge the Program; and

(ii) Shall be reimbursed in accordance with the Department's rate provisions; and

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

(9) Maintain adequate records for a minimum of 6 years and make them available, upon request, to the Department or its designee;

(10) Accept payment by the Program as payment in full for covered services rendered and make no additional charge to any person for covered services;

(11) Provide services without regard to race, color, age, sex, national origin, religion, sexual orientation, marital status, or physical or mental disability;

(12) Verify the participant's eligibility by:

(a) Viewing the participant's Medical Assistance card and another identification card; and

(b) Calling the Program's Eligibility Verification Interactive Voice Response System (EVS/IVR) or accessing the web-based participant eligibility system;

(13) Place no restriction on a participant's right to select health care providers of the participant's choice, except that a participant in a managed care program shall be required to obtain certain specified Program services from or through the participant's care manager, in accordance with the restrictions imposed by the managed care program;

(14) Not knowingly employ or contract with a person, partnership, or corporation which has been disqualified from the Program to provide or supply services to Medical Assistance participants unless prior written approval has been received from the Department;

(15) Notify the Department or its designee of patient activity or circumstance that affects placement, eligibility, or reimbursement, on the form and at the time specified by the Department;

(16) Maintain the confidentiality of all participant information by not releasing the information without authorization by the participant or as authorized by law;

(17) Have an individual rendering number for practitioners recognized by the Program;

(18) Obtain a referral from a participant's care manager in a manner prescribed by the Department before rendering services, when:

(a) The participant is enrolled in a managed care program; and

(b) The service is included under the managed care program's referral requirements.

(19) Supply a signed service order or prescription that includes the individual rendering number of the ordering or prescribing practitioner, as well as the full name and Medical Assistance number of the participant, when ordering services to be supplied by other providers, such as hospital admission, diagnostic testing, supplies, or pharmacy services;

(20) Ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed;

(21) Provide a participant's medical records at no charge when the records are requested by another physician or licensed provider on behalf of the participant; and

(22) Comply with the requirements of COMAR 10.01.04.12 regarding the designation of an authorized representative;

(23) Place no restriction on a participant's fair hearing appeal rights as a condition of rendering services; and

(24) Comply with provider audits authorized by State and federal law to ensure compliance with Program requirements.

B. Enrollment Effective Date.

(1) Unless a provider is enrolled under the provisions of §B(2) of this regulation, the effective date of a provider's enrollment is the date the Program completes all screenings required by State and federal law, which may include a site visit, following the Program's receipt of the provider's submission of a complete application with all required supporting documents.

(2) If an out-of-State emergency transportation services or emergency services provider meets provider enrollment requirements, the enrollment effective date is the date the provider renders the emergency services.

C. A provider may not seek payment from more than one State agency for the same service.

D. If the Program denies payment or requests repayment on the basis that an otherwise covered service was not medically necessary or preauthorized, the provider may not seek payment for that service from the participant.

E. If the Program denies payment due to late billing, payment from the participant may not be sought.

F. The Program may pay for a covered service rendered by a provider to a participant under any of the following circumstances:

(1) The provider charges for nonparticipants who receive the same service by:

(a) Charging the individual in full for services rendered;

(b) Using a sliding fee scale based on the individual's income;

(c) Waiving all or part of the fee for a specific individual; or

(d) Agreeing to accept what a third party pays as payment in full, whether or not the provider bills individuals who lack this coverage;

(2) The State, using its own funds, pays for services rendered to a targeted group of nonparticipants, and the provider charges nontargeted users of the services;

(3) The provider bills all individuals with third party coverage, whether or not the provider bills individuals who lack this coverage;

(4) The service is offered by or through the State agency which administers the program of services authorized under Title V of the Social Security Act; or

(5) The service is offered to a handicapped child receiving services under the Education for the Handicapped Act (EHA) under an individualized education plan (IEP).

G. The following types of providers shall comply with the requirements of 42 CFR Part 489, Subpart I, Advance Directives:

(1) Acute hospitals under COMAR 10.09.92;

(2) Chronic hospitals under COMAR 10.09.93;

(3) Special pediatric hospitals under COMAR 10.09.94;

(4) Special psychiatric hospitals under COMAR 10.09.95;

(5) Nursing facilities under COMAR 10.09.10 and COMAR 10.09.11;

(6) Home health agencies under COMAR 10.09.04;

(7) Personal care case monitors under COMAR 10.09.20;

(8) Model waiver nursing services providers under COMAR 10.09.27; and

(9) Hospices under COMAR 10.09.35.

Md. Code Regs. 10.09.36.03

Effective date:
Regulations .03 adopted as an emergency provision effective July 1, 1990 (17:15 Md. R. 1851); adopted permanently effective October 1, 1990 (17:18 Md. R. 2201)
Regulations .03A amended, and .03D adopted as an emergency provision effective February 27, 1992 (19:6 Md. R. 669); adopted permanently effective June 22, 1992 (19:11 Md. R. 1015)
Regulation .03 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 .03A amended effective June 14, 2010 (37:12 Md. R. 800); December 10, 2012 (39:24 Md. R. 1577); November 11, 2013 (40:22 Md. R. 1877)
Regulation .03 amended effective 42:3 Md. R. 316, eff.2/16/2015; amended effective 43:6 Md. R. 407, eff.3/28/2016; amended effective 43:13 Md. R. 713, eff. 7/4/2016; amended effective 44:26 Md. R. 1215, eff. 1/1/2018; amended effective 45:9 Md. R. 461, eff. 5/7/2018; amended effective 50:18 Md. R. 794, eff. 9/18/2023