Sec. 10.09.23.07. Payment Procedures

A. Request for payment of services shall be submitted in accordance with COMAR 10.09.36.04.

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

C. Rates for services provided by chiropractors, speech therapists, occupational therapists, and nutritionists covered under this chapter are included in the Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Manual.

D. Reimbursement of Medically Monitored Intensive Inpatient Treatment Services Provided in an Intermediate Care Facility.

(1) The Department may not directly reimburse any State-operated intermediate care facility for recipients. The Department shall claim federal fund recoveries from the Department of Health and Human Services for services to federally eligible Title XIX patients in these intermediate care facilities.

(2) The Department shall pay the intermediate care facility the lesser of:

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

(b) The provider’s per diem costs for covered services according to the principles established under Title XVIII of the Social Security Act, up to a maximum of $400 per day.

(3) The maximum payment in §D(2)(b) of this regulation will be updated annually by the Centers for Medicare and Medicaid Service’s published federal fiscal year market basket increase percentage relating to hospitals excluded from the prospective payment system.

(4) Submitting Cost Reports.

(a) Facilities reimbursed according to Medicare standards and principles for retrospective cost reimbursement as described in 42 CFR §413.40, as amended, shall submit to the Department or its designee, in the form prescribed, financial and statistical data within 3 months after the end of the provider's fiscal year unless the Department grants the provider an extension or the provider discontinues participation in the Program. If reports are not received within 3 months and the Department has not granted an extension, the Department shall withhold from the provider a maximum of 10 percent of the current interim payment for the calendar month in which the report is due and any subsequent calendar month until the report has been submitted. There may not be a refund or adjustment for withholding in cost settlement.

(b) If a provider discontinues participation, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination.

(c) The Department may grant an extension if:

(i) The provider makes a written request setting forth the specific reasons for the request; and

(ii) The Department determines, taking into consideration the totality of the circumstances, that the request is reasonable.

(d) If a report is not submitted by the last day of the 6th month after the end of the provider's fiscal year, and the provider has not received an extension, the Department, in addition to withholding percentages of payment pursuant to §D(3)(a) of this regulation, may impose one or more sanctions as provided for in Regulation .09 of this chapter.

(e) If a report is not submitted by the last day of the 6th month after the end of the provider's fiscal year, or a report is submitted but the provider cannot furnish proper documentation to verify costs, the Department, if applicable, shall make final cost settlement for that fiscal year at a certain percentage of the last final per diem rates for which the Department has verified costs for that facility, provided that the rates established may not exceed the maximum per diem rates in effect when the facility's costs were last settled.

(f) For purposes of §D(3)(a)-(e) of this regulation, reports are considered received when the submitted reports are completed according to instructions issued by the Department.

(5) Recipient's Contribution.

(a) The local department of social services or the State-operated facility's fiscal agent shall determine the amount the recipient has available to pay toward the cost of medical or remedial care for inpatient services, and so inform the provider.

(b) The provider shall collect from the recipient that amount as shown available on the designated form.

(c) The provider may not collect a total amount, including the recipient's resource and the Department's payment, which exceeds the provider's rate established by the Department.

(d) The provider shall show to the Department sums collected from the recipient.

E. Reimbursement for environmental lead investigation is $333.29 per inspection.

F. Reimbursement for services covered in Regulation .04 of this chapter shall be the lower of the provider's charge for the service, or the Program's fee schedule.