Sec. 10.09.05.07. Payment Procedures

A. To obtain compensation from the Department for covered services, the provider shall submit a request for payment on the form designated by the Department with the following data or attachments:

(1) If applicable, the preauthorization number shall be inserted in the designated appropriate field on the invoice claim form;

(2) If applicable, pathology reports shall be attached to the claim form; and

(3) If applicable, comprehensive narratives shall be attached to the claim form for those services that are "By Report".

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

C. All prosthetic appliances shall be inserted in the mouth and adjusted before the Program is billed, except when the patient has expired, cannot be located, or refuses to return for completion of treatment. In these cases, the Department will reimburse the provider 80 percent of the maximum State fee for the procedure code for the laboratory bill only.

D. The provider shall charge 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 §E of this regulation; and

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

E. The current Maryland Medicaid Dental Services Fee Schedule and Procedure Codes CDT is incorporated by reference, effective January 1, 2018.

F. The provider shall be paid 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 rate in accordance with the Department’s fee schedule.

G. Pursuant to Regulation .03F of this chapter, to obtain compensation from the Department for rendering services outlined in Regulation .04C of this chapter, the provider shall:

(1) Inform the participant in writing of the $800 annual cap on Medicaid coverage; and

(2) Obtain the participant’s written approval before beginning any services that cannot be completed within the cap amount.

H. The provider may not bill the Department or the participant 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 participant’s medical record when requested by another licensed provider on the participant’s behalf.

I. Reimbursement for Traditional Orthodontic Treatment.

(1) The Program shall reimburse for orthodontic treatment for a maximum of 24 treatment months at an established per monthly rate, provided the treatment meets the standards established in COMAR 10.09.05.06F.

(2) Preauthorization for the treatment is valid for 6 months.

J. Reimbursement for Self–Ligating Braces.

(1) The Program shall reimburse for:

(a) A pre-orthodontic visit;

(b) Comprehensive orthodontia; and

(c) A maximum of 12 periodic treatment visits at an established rate, provided the treatment meets the standards established in COMAR 10.09.05.06F.

(2) When a claim is submitted to the Program for the banding of self-ligating braces, the following documentation shall be submitted with the claim:

(a) A photograph of the recipient’s oral cavity to confirm the placement of self-ligating braces; and

(b) A statement signed by the parent or guardian of the child receiving treatment, acknowledging that:

(i) Orthodontic services are a once in a lifetime benefit; and

(ii) The participant will not be able to pursue additional orthodontic services from the Medicaid Program at a later date.

K. The Department may not make direct payment to nurses, dental assistants, anesthetists, or dental hygienists.

L. The Department may not make direct payment to the participant.

M. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06.

N. Those dental clinics licensed as part of a hospital in Maryland may charge and be reimbursed according to rates approved by the Health Services Cost Review Commission (HSCRC) pursuant to COMAR 10.37.03.

O. Payment for assistant surgeons' services is a maximum of 20 percent of the listed fee paid to the primary surgeon or the fee as determined by the Program for the treatment rendered. The minimum allowance is $25 or the dentist's charge, whichever is lower.