Md. Code Regs. 10.21.17.03

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.21.17.03 - Authorization and Payment

A. Authorization for Services.

(1) The program shall comply with the provisions of this regulation when the program provides services to:

(a) A Medicaid recipient; or

(b) An individual for whom, because of the severity of the mental illness and, based on the Administration's determination of the individual's ability to pay, the cost of care is subsidized, wholly or in part, through the public mental health system.

(2) Before rendering services to an individual, a provider shall notify the Administration's administrative services organization (ASO), or for those services approved by the CSA, the CSA of the jurisdiction where the individual resides, as appropriate, and receive preauthorization for services, according to the provisions of COMAR 10.09.70.07A.

(3) When the Administration's ASO contacts a program directly to refer an individual, and the individual does not make an initial appointment or does not keep the initial appointment, program staff shall:

(a) Attempt to reschedule an initial appointment for the individual; and

(b) If that fails, notify the Administration's ASO that the individual has not received services.

(4) Preauthorization is not required before a provider renders services in an emergency.

(5) If a program discontinues admissions, the program director shall notify the CSA and the Administration's ASO, if appropriate.

B. Payment for Services.

(1) Fee Schedule. The Administration shall reimburse an eligible provider for rendering authorized services:

(a) In accordance with the State budget;

(b) According to the provisions of and at the rates established under COMAR 10.21.25; or

(c) Pursuant to grants or contracts funded by the State or the CSAs.

(2) If an individual is not a Medicaid recipient and, because of the severity of the individual's mental illness and financial need, the cost of the individual's care is subsidized wholly or in part with public funds, the provider shall:

(a) Receive payment if the individual meets eligibility criteria established by the Administration;

(b) Collect information from an individual to assess the individual's ability to pay, including information regarding any applicable insurance benefits;

(c) Assess the individual's ability to pay and determine the required co-payment; and

(d) Make collections of the co-payment according to the requirements in Health-General Article, §§16-201 -16-204, Annotated Code of Maryland.

(3) Medicare Recipients.

(a) If a provider renders services to individuals who are Medicare recipients, the provider shall comply with all federal Medicare requirements.

(b) If a provider does not comply with all Medicare requirements, the provider may not seek reimbursement by the PMHS.

Md. Code Regs. 10.21.17.03

Regulations .03 adopted effective January 14, 2008 (35:1 Md. R. 19)