Sec. 10.09.02.07. Payment Procedures

A. The provider shall submit the request for payment on the form designated by the Department.

B. The Department reserves the right to return to the provider, before payment, all invoices not properly signed, completed, and accompanied by properly completed forms required by the Department.

C. The Provider shall charge the Program the provider’s customary charge to the general public for similar services, except for injectable drugs, the provision of diagnostic or therapeutic radiopharmaceuticals, and dispensed medical supplies, in which case, the provider shall charge the Program the provider’s acquisition cost. 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 §D of this regulation; and

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

D. The Maryland Medical Assistance Program’s procedures for payment are contained in the Professional Services Provider Manual and Fee Schedule (Effective January 2019). All the provisions of this document, unless specifically excepted, are incorporated by reference.

E. The Department will pay for covered services at the lesser of:

(1) Physician’s customary charge or acquisition cost unless the service is free to individuals not covered by Medicaid; or

(2) The Department's fee schedule.

F. The Program reserves the right to negotiate and establish a different fee for a physician or a group of physicians under contract to a hospital to provide services when a portion of the cost of the contract is paid as the hospital's cost, provided this fee does not exceed limitations set forth in §E of this regulation.

G. Supplemental payments on Medicare claims are made subject to the following provisions:

(1) Deductible insurance will be paid in full;

(2) Beginning with August 1, 2010 dates of service, and subject to the limitations of the State budget, 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 are payable according to §E of this regulation.

H. Payments on Medicare claims are authorized if the:

(1) 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. The provider may not bill the Department or the recipient for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Professional services rendered by mail or telephone; or

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

J. The Program will make no direct payment to recipients.

K. The Program will reimburse the provider for dispensed drugs at rates established in COMAR 10.09.03. The provider shall bill the Program in accordance with COMAR 10.09.03 using the Pharmacy Invoice.

L. The program will reimburse the provider for injectable drugs at rates promulgated by the fee schedule under §D of this regulation.

M. The Program will reimburse the provider for dispensed medical supplies at actual cost or at rates established by COMAR 10.09.12, whichever is less.

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

O. Providers shall bill the Program in the following manner:

(1) A physician whose laboratory is not required to be registered pursuant to Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, shall bill the Program for laboratory services in accordance with procedures required under these regulations;

(2) A physician whose laboratory is registered as a medical laboratory pursuant to Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, shall bill the Program for laboratory services in accordance with procedures required under COMAR 10.09.09.

P. Reimbursement.

(1) The Program shall reimburse providers for all laboratory and other diagnostic services performed by a physician, or by authorized personnel under that physician's supervision, for that physician's patients.

(2) Reimbursement shall be according to all applicable provisions of COMAR 10.10.06 and fees established under COMAR 10.09.02.

(3) Maximum reimbursement may not exceed the Medicare laboratory fee established by the Maryland Medicare carrier recognized by the Program.

(4) The Program shall reimburse providers for mental health services performed by a physician according to the fees established under COMAR 10.21.25 and the requirements of this chapter.

Q. The Program will reimburse the provider for the provision of diagnostic and therapeutic radiopharmaceuticals at actual cost.