Md. Code Regs. 10.09.77.06

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

Section 10.09.77.06 - Payment Procedures

A. Payment for free-standing urgent care centers is as follows:

(1) Urgent care centers are reimbursed a facility fee, which is determined by the Program;

(2) In addition to the facility fee, the Program shall reimburse for services rendered by the physician, nurse practitioner, or physician assistant during the visit at the free-standing urgent care center; and

(3) If the service is free to individuals not covered by Medicaid:

(a) The provider:

(i) May charge the Program; and

(ii) Shall be reimbursed in accordance with the provisions of this regulation; and

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

B. Reimbursement by the Program for facility services, which are included in the facility fee, includes:

(1) Nursing, technician, and related services;

(2) Use of the center;

(3) Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances, and any equipment directly related to the treatment of the illness or injury; and

(4) Administrative costs.

C. The Department shall pay for covered services at 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 Department's fee for:

(a) Professional services in accordance with COMAR 10.09.02.07D; and

(b) Laboratory services in accordance with COMAR 10.09.09.07D.

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 that are not properly completed.

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;

(3) Medicare has determined that the services are medically necessary;

(4) Services are covered by the Program; and

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

G. The Department shall make supplemental payment on Medicare claims subject to the limitations of the State budget and the following provisions:

(1) Deductible insurance shall be paid in full;

(2) Beginning with August 1, 2010 dates of service, 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, but considered medically necessary by the Program, will be paid according to the limitations of Regulation .04 of this chapter.

H. The provider may not bill the Program for:

(1) Completion of forms and reports;

(2) Broken or missed appointments; or

(3) Professional services rendered by mail or telephone.

I. The Program may not make a direct payment to a participant.

J. Billing time limitations for claims submitted under this chapter are set forth in COMAR 10.09.36.06A.

Md. Code Regs. 10.09.77.06

Regulation .06G amended effective April 4, 2011 (38:7 Md. R. 430); amended effective 43:13 Md. R. 713, eff. 7/4/2016; amended effective 44:8 Md. R. 404, eff. 4/24/2017; amended effective 48:12 Md. R. 473, eff. 6/14/2021; amended effective 50:13 Md. R. 512, eff. 7/10/2023