Md. Code Regs. 10.09.55.06

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

Section 10.09.55.06 - Payment Procedures

A. The provider shall submit the request for payment in the format designated by the Department.

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

C. The provider shall charge the Program the provider's customary charge to the general public for similar services and charge the provider's acquisition cost for injectable drugs or dispensed medical supplies. 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 Department shall reimburse the physician assistant for covered services at the lesser of:

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

(2) The maximum rates according to COMAR 10.09.02.07E.

E. Payments on Medicare claims are authorized, if:

(1) Services are covered by the 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.

F. The provider may not bill the Program for:

(1) Deductible insurance shall be paid in full; and

(2) Coinsurance shall be paid at the lesser of:

(a) 100 percent of the coinsurance amount; or

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

G. 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; and

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

H. The Program may not make direct payment to participants.

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

J. Physician assistants who are employed by or under contract to any physician, clinic, or hospital may not bill for any service for which reimbursement is sought by the physician, clinic, or hospital.

Md. Code Regs. 10.09.55.06

Regulations .06 effective April 2, 2001 (28:06 Md. R. 620)
Regulations .06 repealed effective April 28, 2014 (41:8 Md. R. 471)
Regulations .06 adopted effective 42:9 Md. R. 647, eff.5/11/2015; amended effective 43:19 Md. R. 1072, eff. 9/26/2016; amended effective 50:13 Md. R. 512, eff. 7/10/2023