Md. Code Regs. 10.09.64.06

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

Section 10.09.64.06 - Payment Procedures

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

B. The Program 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 Program.

C. Unless the service is free to the general public, the provider shall charge the Program the provider's customary charge to the general public for similar services.

D. 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 §G of this regulation; and

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

E. The Program 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 Program's fee schedule.

F. The provider may not bill the Program or the participant for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Professional services rendered by mail;

(4) Professional services rendered via telehealth when services are indicated as an exclusion; or

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

G. Reimbursement.

(1) Providers may bill one 60-minute or 70-minute code per month, and two additional 30-minute codes per month, unless otherwise excepted in §G(2)or (3) of this regulation.

(2) FQHCs may bill once per month, using a separate FQHC code.

(3) If the primary care team determines that the participant's condition requires more or less frequent visits than described above, the care manager may order an alternate schedule.

(4) The Maryland Medical Assistance Program's procedures for payment are contained in COMAR 10.09.02.07D.

Md. Code Regs. 10.09.64.06

Regulations .06 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730)
Regulations .06 adopted effective March 10, 1997 (24:5 Md. R. 408)
Regulation .06 amended as an emergency provision effective July 1, 1998 (25:16 Md. R. 1261); amended permanently effective January 1, 1999 (25:26 Md. R. 1925)
Regulation .06 amended effective June 30, 2008 (35:13 Md. R. 1180)
Regulation .06E amended effective October 28, 2013 (40:21 Md. R. 1775)
Regulation .06 amended effective 42:3 Md. R. 316, eff.2/16/2015; recodified to 10.67.03.06 effective 46:22 Md. R. 976, eff. 11/1/2019; adopted effective 51:15 Md. R. 707, eff. 8/5/2024.