Md. Code Regs. 10.09.14.07

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

Section 10.09.14.07 - Payment Procedures

A. Form for Request for Payment.

(1) The provider shall submit a request for payment on the form designated by the Department.

(2) The request for payment shall document the following, when applicable:

(a) Preauthorization;

(b) Prescriptions;

(c) Need for combination or metal frame;

(d) Laboratory invoices.

B. The Department reserves the right to return to the provider, before payment, all invoices not properly completed.

C. The provider shall charge the Program the provider's customary charge to the general public for similar professional 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 §F of this regulation ;and

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

D. The provider shall charge acquisition cost for eyeglass frames, eyeglass lenses, contact lenses, and other optical aids.

E. Vision care services are reimbursed according to COMAR 10.09.23.01-1.

F. The Department will pay professional fees 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 schedule.

G. The Department will pay for materials at acquisition costs not to exceed the maximums established by the Department.

H. Payments on Medicare claims are authorized if:

(1) The provider accepts Medicare assignments;

(2) Medicare makes direct payment to the provider;

(3) Medicare has determined that services were medically justified;

(4) Services are covered by the Program;

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

I. Supplemental payment on Medicare claims is made subject to the limitations of the State budget and the following provisions:

(1) Deductible insurance will 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 covered by the Program, according to §E, of this regulation.

J. The provider may not bill the Department for:

(1) Services rendered by mail or telephone;

(2) Completion of forms and reports;

(3) Broken or missed appointments; or

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

K. The Department's payment for lenses, frames, case, fitting, and dispensing covers any routine follow-up and adjustments for 60 days, and no additional fees will be paid.

L. The Department will make no direct payment to the recipient.

M. Payment for contact lenses is made as follows:

(1) For the prescription, fitting, training, and adaptation of contact lenses which includes the:

(a) Specification of optical and physical characteristics;

(b) Fitting of lenses to the wearer;

(c) Training of the wearer;

(d) Incidental revision of the lenses during training; and

(e) Adaptation of the lenses to the wearer;

(2) For the supply of contact lenses; and

(3) For the follow-up of successfully fitted extended wear lenses.

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

Md. Code Regs. 10.09.14.07

Regulation .07 amended effective November 29, 1999 (26:24 Md. R. 1858); October 10, 2005 (32:20 Md. R. 1655)
Regulation .07C amended effective April 17, 1981 (8:8 Md. R. 721)
Regulation .07D amended as an emergency provision effective July 1, 1982 (9:13 Md. R. 1347); adopted permanently effective November 1, 1982 (9:21 Md. R. 2106)
Regulation .07D amended as an emergency provision effective July 1, 1984 (11:13 Md. R. 1170); adopted permanently effective October 29, 1984 (11:21 Md. R. 1813)
Regulation .07D amended as an emergency provision effective October 1, 1986 (13:22 Md. R. 2393); adopted permanently effective February 9, 1987 (14:2 Md. R. 129)
Regulation .07D amended effective August 10, 1987 (14:16 Md. R. 1774); January 2, 1995 (21:26 Md. R. 2186)
Regulation .07E amended effective April 9, 1984 (11:7 Md. R. 625); March 24, 2008 (35:6 Md. R. 698); January 12, 2009 (36:1 Md. R. 21)
Regulation .07H amended as an emergency provision effective January 8, 1979 (6:2 Md. R. 72); emergency status extended until June 1, 1979 (6:12 Md. R. 1045); adopted permanently effective June 1, 1979 (6:11 Md. R. 979)
Regulation .07I amended effective April 4, 2011 (38:7 Md. R. 430)
Regulation .07M amended as an emergency provision effective July 1, 1978 (5:14 Md. R. 1131); adopted permanently effective November 3, 1978 (5:22 Md. R. 1673)
Regulation .07M amended effective January 30, 1984 (11:2 Md. R. 113); September 10, 1984 (11:18 Md. R. 1584)
Regulation .07M amended as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004)
Regulation .07M amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004); amended effective 43:13 Md. R. 712, eff.7/4/2016; amended effective 44:4 Md. R. 253, eff. 2/27/2017