Sec. 10.09.12.07. Payment Procedures

A. Payment procedures shall be as set forth in COMAR 10.09.36.04.

B. The provider’s billed charges to the Program may not exceed the provider’s customary charge. If the item is free to individuals not covered by Medicaid:

(1) The provider:

(a) May charge the Program; and

(b) Shall be reimbursed in accordance with the provisions of this regulation; and

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

C. The provider shall give the Program the full advantage of any and all manufacturer's warranty offered on the item.

D. Effective July 1, 2013, the Department shall pay providers 85 percent of the April 2013 Medicare rate for prosthetic devices. For prosthetic devices for which Medicare has not established a rate, the Department shall pay providers the manufacturer's suggested retail price of the item, less 26.5 percent. The payment shall include all fitting, dispensing, and follow-up care.

E. Charges for osteogenesis stimulators shall include all follow-up care, batteries, repairs, and replacement parts within the limitations of Regulation .05E and F, at the following times:

(1) Initial date of service;

(2) After 6-week evaluation;

(3) After 3-month evaluation.

F. The Department shall reimburse providers for the purchase of covered services at the lesser of the provider’s customary charge unless the service is free to individual not covered by Medicaid or:

(1) For items for which Medicare has established a rate:

(a) Disposable medical supplies and durable medical equipment at 85 percent of the April 2013 Medicare purchase reimbursement rate; and

(b) For medical equipment for which Medicare has established a capped rental rate, the purchase price shall be 9 times the current Medicare monthly rental rate; or

(2) For items for which Medicare has not established a rate:

(a) Disposable medical supplies not including incontinence supplies at the provider's choice of the manufacturer's suggested retail price minus 41.2 percent or the provider's wholesale cost plus 37.2 percent;

(b) Incontinence supplies at the provider's wholesale cost plus 25 percent;

(c) Customized equipment at the provider's choice of the manufacturer's suggested retail price minus 30 percent or provider's wholesale cost plus 40 percent; and

(d) Other durable medical equipment at the provider's choice of the manufacturer's suggested retail price minus 41.2 percent or provider's wholesale cost plus 27.4 percent.

G. The Department shall reimburse providers for the monthly rental of covered services as follows:

(1) For items for which Medicare has established a purchase rate, 9 percent of the current Medicare purchase reimbursement rate; and

(2) For items for which Medicare has not established a rate, 10 percent of the purchase price as determined in §F(2) of this regulation.

H. The Department reserves the right to prorate the monthly rental amount for daily rentals.

I. The Department shall pay for repairs to purchased durable medical equipment according to the following:

(1) The provider's choice of wholesale cost plus 37.2 percent or the manufacturer's suggested retail price minus 31.4 percent to the provider for all materials;

(2) Labor costs shall be billed in quarter hour increments using the appropriate procedure code and shall be reimbursed the lesser of:

(a) The supplier’s customary charge unless the service is free to individual not covered by Medicaid; or

(b) The reimbursement rate specified in the Medicaid Durable Medical Equipment Program's approved list of items.

J. The determination to purchase or rent medical equipment shall be based on the prescriber's best faith estimate of length of time the equipment will be needed by the recipient. When the equipment is ordered for:

(1) 12 or more months, the provider shall charge the Program for a purchase, unless:

(a) There is justification to request a rental rather than a purchase of the item, and a request for prepayment authorization is submitted to and approved by the Program; and

(b) The request for prepayment authorization is approved by the Program before the submission of the invoice for the item;

(2) Less than 12 months, the provider shall charge the Program for rental of the item for the duration of the medical necessity except that:

(a) If the equipment is still medically necessary after 12 months of rental, a final thirteenth rental payment shall be made and the equipment is considered purchased by the Program; or

(b) If there is justification to request a purchase rather than a rental of the item, a request for prepayment authorization shall be submitted to the Program and approved by the Program before the submission of the invoice.

K. Medical equipment that is determined by the Department to require frequent and substantial servicing in order to avoid risk to the recipient's health shall be reimbursed at the rental rate in accordance with §G of this regulation until either the equipment is no longer medically necessary or the recipient is no longer eligible for Medical Assistance fee-for-service benefits.

L. Every 90 days during the rental term the provider shall obtain recertification from the prescriber and keep in the provider's records a recertification of continuous medical need that the equipment is still medically necessary.

M. The Department shall review purchase prices and rental charges for items for which Medicare has not established a rate at least every 3 years.

N. If services are provided under a contract pursuant to Regulation .04F of this chapter, the Department shall reimburse the contracted vendor or vendors at rates and under conditions in accordance with the contract or contracts.

O. Once an item has been purchased in full, then title to the equipment shall remain with the Department, and the equipment, after use by the recipient, shall be recovered by the Department or its designee. The Department may arrange for the provision of recycled equipment under an exclusive contract with a vendor or vendors that have been awarded in accordance with State regulations and policies governing contracts and procurement. The Department also may determine the geographical scope and the types of equipment, or both, to be included under the contract. The vendor or vendors shall be reimbursed at a rate and under terms established in the contract.

P. For equipment that is not covered under a contract awarded under §O of this regulation, the provider that originally furnished the equipment to the recipient shall recover the equipment after it is no longer required by the recipient. After recovery of the equipment, the provider shall determine the viability of recycling the item and, upon its reissue, bill the Program 75 percent of the Program's original payment.

Q. To the extent that the Department chooses to use an exclusive contract to provide recycled equipment under §O of this regulation, the Department shall reimburse providers for evaluation of a recipient for equipment that is subsequently provided through the Department's recycling program at 11.5 percent of the reimbursement rate established under §§A-H of this regulation.

R. The Department will authorize payment on Medicare claims 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) The services are covered by the Program;

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

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

(1) Deductible insurance will be paid in full;

(2) Coinsurance will be paid in full;

(3) Services not covered by Medicare, but by the Program, will be paid in accordance with the limitations of §I of this regulation.

T. The provider may not bill the Department for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

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

(4) Fitting, dispensing, or follow-up care except as set forth in §D of this regulation.

U. The methodology in §§F and G of this regulation shall be used to establish a list of approved items with the corresponding procedure code, maximum allowable reimbursement amount, useful life expectancy, and maximum number allowed. This list shall be made available to the providers for ease of administration of the Program. When the approved list of items contains a price for a procedure code, the Department shall reimburse providers the lesser of the price listed in the approved list or the provider’s customary charge unless the service is free to individuals not covered by Medicaid.

V. The provider shall ensure that the equipment is in good working condition both throughout the rental of the equipment and at the end of the rental term.

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

X. Durable medical equipment and disposable medical supply rates may be increased at the Program's discretion, when the Program determines in its sole discretion that the Medicare rate creates a barrier to accessing medical equipment and supplies.

Y. Refills.

(1) For durable medical equipment or disposable supplies, or both that are supplied as refills to the original order, providers shall contact the recipient or designee before dispensing the refill in order to ensure that the refilled item is necessary and to confirm any changes and modifications to the order.

(2) The provider shall maintain documentation of contact and confirmation of any changes and modifications of the order for audit purposes.

(3) The provider shall contact the recipient or designee regarding refills no earlier than 7 business days before the anticipated delivery date or anticipated shipping date.

(4) For subsequent deliveries of refills, the provider shall deliver the items no earlier than 5 days before the end of usage for the current product.

Z. The disposable medical supplies or durable medical equipment provider shall identify the individual who ordered the disposable medical supplies and durable medical equipment by recording the individual practitioner’s National Provider Identifier (NPI) number on the claim.