Md. Code Regs. 10.09.69.15

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

Section 10.09.69.15 - Appeals Procedures

A. A provider shall submit a request for payment for the services covered under this chapter according to the procedures set forth in COMAR 10.09.36.

B. Billing time limitations for the services covered under this chapter are the same as those set forth in COMAR 10.09.36.

C. The Department shall pay for covered services at the lower of:

(1) The lowest price, including negotiated contract prices, that is offered to any other purchaser for the same or similar service during the same time period, after extending to the Program all rebates, coupons, and negotiated discounts;

(2) The actual charge billed by the provider; or

(3) Any fee schedule developed for reimbursement of the same service provided under Medicaid.

D. Payment for all services covered under this chapter are reimbursed on an all inclusive basis.

E. Effective January 1, 2011, the Department shall pay $388.55 for case management assessment, as described in Regulation .05C of this chapter.

F. Effective January 1, 2011, the Department shall make payments monthly for case management services at one of the rates specified below:

(1) Level of Care 1: $286.90;

(2) Level of Care 2: $171.00; or

(3) Level of Care 3: $90.25.

G. The rates found in §F of this regulation are the monthly rates paid by the Department for an individual receiving case management as follows:

(1) Level of Care 1 is intensive level of case management, assessment, and coordination of services for an individual who:

(a) Is acutely ill;

(b) Has an unstable clinical condition;

(c) Has an exacerbated chronic illness; or

(d) Has a newly diagnosed condition;

(2) Level of Care 2 is case management to an individual who has a history of exacerbations of medical issues requiring services on an ongoing basis to attain stable service or treatment plans; and

(3) Level of Care 3 is case management that is required on an ongoing basis to monitor a recipient's stability and treatment plans.

Md. Code Regs. 10.09.69.15

Regulations .15 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730)
Regulations .15 adopted effective March 10, 1997 (24:5 Md. R. 408)
Regulations .15 adopted effective February 2, 2004 (31:2 Md. R. 84); recodified from .14 effective 45:13 Md. R. 665, eff. 7/2/2018