Sec. 10.09.18.07. Payment Procedures

A. The provider shall submit request for payment on the forms designated by the Department, with attachments when applicable.

B. The Department reserves the right to return to the provider, before payment, all invoices not properly signed and completed and those submitted without required documentation.

C. The provider shall charge the Program the provider’s customary charge to the general public for similar items. 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 §D of this regulation; and

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

D. The Department shall reimburse providers for the purchase of covered services at the lowest of the provider's customary charge:

(1) For items that Medicare has established a rate:

(a) Effective July 1, 2013, the Department shall pay providers 85 percent of the April 2013 Medicare rate for oxygen and respiratory equipment and supplies, which shall include all fitting, dispensing, and follow-up care; and

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

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

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

(c) Other oxygen and respiratory equipment at the provider's choice of the manufacturer's suggested retail price minus 41.2 percent or of the provider's wholesale cost plus 27.4 percent.

E. The Department shall pay for repairs to purchased oxygen and respiratory equipment in accordance with the following:

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

(2) Reasonable charges for labor, not to exceed the customary charges for similar services in the provider’s area unless the service is free to individuals not covered by Medicaid; or

(3) Actual charges for repairs done by other than the provider as evidenced by an invoice attached to the bill.

F. The Department shall only pay separately for the following replacement items for purchased respiratory equipment, and all other replacement items shall be included in repairs and will be reimbursed according to §E of this regulation:

(1) Mouthpiece;

(2) Face mask;

(3) Tracheostomy collar or T-tube.

G. When any individual item or combination of items are provided as part of a complete setup, they may not be invoiced in the Program separately, but under complete setup procedure codes as listed in the fee schedule, except for replacement items as listed in §F of this regulation.

H. The Program will approve for payment the least expensive mode of oxygen which is medically suited for the patient's condition.

I. The Program will determine, based upon expected duration of medical need, whether oxygen related equipment will be purchased or rented. Once an item has been purchased and paid for in full, and if the Program has contributed in full or in part to the purchase, then title to the equipment shall remain with the Department, and the equipment, after use by the recipient, shall be recovered at the option of the Department.

J. Supplemental payment on Medicare claims is made subject to the following provisions:

(1) Deductible insurance will be paid in full;

(2) Co-insurance will be paid in full;

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

K. 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; and

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

L. The Department may not make direct payments to recipients.

M. The provider may not bill the Program for:

(1) Services rendered by mail or telephone;

(2) Completion of forms or reports; or

(3) Broken or missed appointments.

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

O. Oxygen and respiratory 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 oxygen and respiratory equipment and supplies.

P. Refills.

(1) For oxygen and respiratory equipment and supplies 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 contact recipient or designee regarding the refills no earlier than 7 days before the delivery and shipping date.

(3) 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.