Md. Code Regs. 10.09.87.07

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

Section 10.09.87.07 - Payment Procedures

A. General policies for payment that are applicable to all providers are set forth in COMAR 10.09.36.04.

B. IDTF providers shall identify the individual who ordered the diagnostic services by either:

(1) Recording the National Provider Identifier (NPI) number for the individual provider on the claim; or

(2) Recording the name and NPI of the authorized ordering provider on the invoice and attaching to the invoice a copy of the properly completed order that identifies the authorized ordering provider.

C. The Department shall reimburse the IDTF providers 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 Department's fee schedule.

D. The Department's fee-schedule is contained in COMAR 10.09.02.07D.

E. Payments on Medicare cross-over claims are authorized 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) Initial billing is made directly to Medicare according to Medicare guidelines.

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

(1) 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 Program may not make a direct payment to a recipient.

H. Billing time limitations are those set forth in COMAR 10.09.36.06

I. The provider may not bill the Program or recipient for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Services rendered by mail or telephone; and

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

Md. Code Regs. 10.09.87.07

Effective date: 41:8 Md. R. 472, eff.4/28/2014 ; Regulations .07 amended effective 43:13 Md. R. 713, eff. 7/4/2016; amended effective 44:4 Md. R. 252, eff. 2/27/2017; amended effective 44:26 Md. R. 1214, eff. 1/1/2018