Md. Code Regs. 10.09.36.04

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

Section 10.09.36.04 - 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 Department reserves the right to return to the provider, before payment, all claims not properly signed, completed, and accompanied by properly completed forms required by the Department.

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

D. All payments are contingent upon a provider's full compliance with the requirements of its enrollment and applicable conditions of participation.

E. Unless the service is free to the general public, the provider shall charge the Program its customary charge to the general public for similar services.

F. Unless otherwise excepted, the provider shall be paid the lesser of:

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

(2) The Department's applicable rate.

G. Unless otherwise excepted, if a service is free to individuals not covered by the Program:

(1) The provider:

(a) May charge the Program; and

(b) Shall be reimbursed in accordance with §F of this regulation; and

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

H. Providers may not bill the Department or the Program for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Professional services rendered by:

(a) Mail;

(b) Email; or

(c) Fax; or

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

I. Unless otherwise excepted, payments on Medicare claims are authorized, if:

(1) Services are covered by the Medicare Program;

(2) The provider accepts Medicare assignments;

(3) Medicare makes direct payment to the provider;

(4) Medicare has determined that services were medically justified; and

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

J. Unless otherwise provided by regulation, 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 §F of this regulation.

K. An individual or entity who is employed by or under contract to any group provider, clinic, or hospital may not bill for any service for which reimbursement is sought by the group provider, clinic, or hospital.

Md. Code Regs. 10.09.36.04

Regulations .04 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); amended effective 51:15 Md. R. 707, eff. 8/5/2024.