Md. Code Regs. 10.09.42.06

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

Section 10.09.42.06 - Payment Procedures

A. The Program reimburses a facility fee when the free-standing Medicare certified ambulatory surgery center provides a covered surgical procedure, in accordance with 42 CFR § 416.166 to an eligible Medicaid recipient. Reimbursement for the facility fee includes, but is not limited to the following:

(1) Nursing, technician, and related services;

(2) Use of the facility;

(3) Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances, and any equipment directly related to the provision of surgical procedures;

(4) Administrative costs;

(5) Materials including supplies and equipment for the administration and monitoring of anesthesia;

(6) Radiology services for which separate payment is not allowed and other diagnostic tests or interpretive services that are integral to a surgical procedure;

(7) Supervision of the services of a nurse anesthetist by the operating surgeon;

(8) Ancillary items and services that are integral to a covered surgical procedure as defined in 42 CFR § 416.166; and

(9) Any laboratory testing performed under a Clinical Laboratory Improvement Amendment of 1988 (CLIA) certificate of waiver.

B. Reimbursement Methodology:

(1) Reimbursement fees equal 80 percent of the current Medicare-approved ASC facility fee for services furnished to Medicaid recipients in connection with covered surgical procedures.

(2) If one covered surgical procedure is furnished to a recipient, payment is at the Maryland Medicaid Program payment amount which is 80 percent of the current Medicare approved facility fee for that procedure.

(3) If more than one covered surgical procedure is provided to a recipient in a single operative session, payment is made at 100 percent of the Maryland Medicaid Program payment amount for the procedure with the highest reimbursement rate. Other covered surgical procedures furnished during the same session are reimbursed at 50 percent of the Maryland Medicaid Program payment amount for each procedure.

(4) When a covered surgical procedure is terminated before the completion due to extenuating circumstances or circumstances that threaten the well-being of the patient, the Medicaid Program payment amount is based on one of the following:

(a) If the covered procedure for which the anesthesia is planned is discontinued after the induction of anesthesia or after the procedure is started, the reimbursement amount is 80 percent of the current Medicare approved facility fee; or

(b) If the patient is prepared for surgery and the surgery is then cancelled before the induction of anesthesia, reimbursement shall be 50 percent of Maryland Medicaid payment amount.

C. Dental services rendered in an ASC on or after December 1, 2014, shall be reimbursed as follows:

(1) For covered dental services that have a reimbursement amount of $1,000 through $2,999.99, the ASC facility fee will be $600;

(2) For covered dental services that have a reimbursement amount of $3,000 through $4,999.99, the ASC facility fee will be $1,250;

(3) For covered dental services that have a reimbursement amount of $5,000 through $7,999.99, the ASC facility fee will be $2,500; and

(4) For covered dental services that have a reimbursement amount of $8,000 and over, the ASC facility fee will be $3,000.

D. The provider shall submit a request for payment as set forth in COMAR 10.09.36.04A.

E. The Program reserves the right to return to the provider, before payment, all invoices not properly completed, including but not limited to, diagnostic and procedure codes and description of services provided.

F. The Program shall authorize payment on Medicare claims only if:

(1) The provider accepts Medicare assignment;

(2) Medicare makes direct payment to the provider; and

(3) Medicare has determined that the services are medically justified, excludes dental services.

G. The Department shall make supplemental payment on Medicare cross-over claims subject to the following provisions:

(1) Deductible is paid in full;

(2) Coinsurance shall be paid lesser of:

(a) 100 percent of the coinsurance amount; or

(b) The balance remaining after the Medicare payment is subtracted from the Medicaid rate; and

(3) Services not covered by Medicare, but considered medically necessary by the Program, according to the limitations of Regulation .04C of this chapter.

H. The provider may not bill the Program for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Professional services rendered by mail or telephone; or

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

I. The Program shall make no direct payment to a recipient.

J. The Program shall make no separate direct payment to any person employed by or under contract to any free-standing Medicare-certified ambulatory surgical center facility for services covered under this regulation.

K. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06A.

Md. Code Regs. 10.09.42.06

Regulation .06 amended effective April 5, 2010 (37:7 Md. R. 571)
Regulation .06B amended effective April 12, 2004 (31:7 Md. R. 584)
Regulation .06 amended effective 42:5 Md. R. 485, eff.3/16/2015; amended effective 43:13 Md. R. 713, eff. 7/4/2016