Md. Code Regs. 10.09.08.10

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

Section 10.09.08.10 - Payment Procedures

A. The provider shall submit a completed request for payment in the format designated by the Department with any required documentation.

B. The Program reserves the right to return to the provider, before payment, all invoices not properly completed with a diagnosis, procedure code, and description of the services provided.

C. The provider shall bill the Program the provider's customary charge to the general public for similar services. 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 COMAR 10.09.02.07D; and

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

D. The Department shall authorize payment on Medicare cross-over claims only if:

(1) The provider accepts Medicare assignments;

(2) Medicare makes direct payment to the provider;

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

(4) The services are covered by the Program; and

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

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

(1) A deductible shall be paid in full;

(2) 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; and

(3) Services not covered by Medicare, but considered medically necessary by the Program, shall be paid according to the limitations of this chapter.

F. The provider may not bill the Program for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Professional services rendered by mail;

(4) Home visits unless specifically authorized by federal law or regulation;

(5) More than one visit to complete an EPSDT screen; and

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

G. The Program may not make direct payment to participants.

H. The Program may not make a separate direct payment to any person employed by or under contract to any freestanding clinic for services provided in a freestanding clinic.

I. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.

Md. Code Regs. 10.09.08.10

Regulation .10 amended effective June 6, 1983 (10:11 Md. R. 974)
Regulations .10 repealed effective October 1, 1985 (12:19 Md. R. 1849)
Regulations .10 adopted effective October 1, 1985 (12:19 Md. R. 1849)
Regulation .10 adopted effective 42:6 Md. R. 512, eff.4/1/2015; amended effective 43:13 Md. R. 712, eff.7/4/2016; amended effective 43:21 Md. R. 1166, eff. 10/24/2016; amended effective 44:4 Md. R. 252, eff. 2/27/2017; amended effective 50:20 Md. R. 886, eff. 10/16/2023