Sec. 10.09.26.13. Payment Procedures

A. Request for Payment.

(1) All requests for payment of services rendered shall be submitted according to procedures established by the Department. Payment requests which are not properly prepared or submitted may not be processed, but shall be returned unpaid to the provider.

(2) Requests for payment shall be submitted as set forth in COMAR 10.09.36.04A.

(3) Requests for payment shall include all units of service rendered to a waiver participant during the billing period.

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

C. Payments.

(1) Payments shall be made only to a qualified provider. Payment may not be made to a waiver participant, to individual professionals, or to other Program providers in connection with the provision of services specified in Regulations .04-.08-5 of this chapter.

(2) Payments to service coordination providers shall be made according to a monthly waiver participant fee negotiated with the DDA.

(3) Payments to residential habilitation service providers or to day habilitation service providers during their first year of operation, to most intensive behavior management providers, to some residential option providers, and to most supported employment providers which are licensed under COMAR 10.22.13 shall be made on a cost-related basis. This includes the following:

(a) The Department shall pay these providers an interim payment based on allowable costs included in the human services agreement between DDA and the provider. The final cost settlement shall be actual allowable cost as determined by the Department through the audit and post-audit settlement process specified in COMAR 10.04.03 and 10.04.04. Tentative cost settlements may be made using unaudited annual reports submitted by providers to the Department.

(b) Allowable costs are those costs incurred in the delivery of the covered services delineated in this chapter.

(c) Return on equity is not an allowable cost.

(d) A provider fee as specified in COMAR 10.09.41 is an allowable cost.

(e) Room and board is an allowable cost only for respite care provided under Regulation .08 of this chapter.

(f) Payments to these providers shall be on a quarterly basis. Providers shall submit quarterly reports of expenditures and requests for payment in the prescribed form to the Division of Program Cost and Analysis of the Maryland Department of Health. Providers shall receive funds in advance of expenditures anticipated in the ensuing quarter of the fiscal year.

(4) Payments to most residential habilitation and day habilitation service providers, some intensive behavior management providers, and some supported employment and residential option providers shall be made according to the prospective payment system specified in COMAR 10.22.17.

(5) Payments to medical day care service providers shall be in accordance with COMAR 10.09.07 and the waiver participant's approved plan of care.

(6) Notwithstanding any other provision of these regulations, payment may not be made under these regulations for respite care or environmental modifications, as defined in Regulation .01B of this chapter, until the §1915(c) waiver amendment authorizing coverage of these services has been approved by the Health Care Financing Administration (HCFA). Once HCFA has approved the waiver amendment, payments may be made for respite care and environmental modifications retroactive to the effective date of the waiver amendment, but not earlier than April 1, 1991.

(7) Notwithstanding any other provision of these regulations, payment may not be made under these regulations for residential option or intensive behavior management services, as defined in Regulation .01B of this chapter, or for services delivered to an individual being discharged or diverted from a chronic care facility, until the waiver amendment under the Social Security Act, Title XIX, §1915(c), authorizing coverage of these services has been approved by the Health Care Financing Administration (HCFA). Once HCFA has approved the waiver amendment, payments may be made retroactive to the effective date of the waiver amendment.

D. Cost Reporting.

(1) The provider shall maintain adequate financial records and statistical data according to generally accepted accounting principles and procedures. This system of accounts shall provide at a minimum:

(a) Maintenance of a chronological cash receipts and disbursements journal in sufficient detail to show the exact nature of the receipts and disbursements.

(b) Proper reference to supporting invoices, voucher, or other form of original evidence.

(c) Maintenance of an appropriate time reporting system for all personnel and proper payroll authorizations and vouchers.

(d) Provision for payment by check. When financial transactions involve numerous small expenditures an imprest petty cash fund shall be established, provided adequate supporting vouchers are maintained.

(e) Maintenance of records of all assets.

(f) Maintenance of records on a cash or accrual basis.

(g) Maintenance of records as required by the Department.

(h) Maintenance of all records concerning financial expense and income allocations shall be sufficiently documented by supporting data. Generally accepted accounting principles and the allocation principles of cost accounting theory shall be used for allocation of costs and income.

(i) Maintenance of separate records of financial expense and income allocation applicable to:

(i) Room and board;

(ii) Covered services as specified in Regulations .05-.08-4 of this chapter.

(2) The provider shall keep all records available for inspection or audit by the Department or its designee at any reasonable time during normal business hours. Records shall be maintained for 6 years after the period the cost report to which the materials apply is filed with the Department.

(3) The provider shall:

(a) Report direct and indirect costs applicable to recipient care. These reports shall clearly identify those direct and indirect costs and income applicable to:

(i) Room and board;

(ii) Covered services as specified in Regulations .05-.08-4 of this chapter.

(b) Submit to the Division of Program Cost and Analysis of the Department a year-end reconciliation report of financial data in the prescribed form within 30 days of the end of the fiscal year unless the Department grants the provider an extension.

E. Application of Recipient Income to Cost of Care.

(1) The Department of Human Services shall determine the application of Optional Categorically Needy recipient's income toward the cost of services specified in Regulations .05 and .08 of this chapter pursuant to Regulation .12B of this chapter.

(2) The residential habilitation services provider shall collect the Optional Categorically Needy recipient's available income as certified by the Department of Human Services.

(3) The total of an Optional Categorically Needy recipient's available income to be applied to the cost of care and the Department's payment may not exceed the total cost of services specified in Regulations .05 and .08 of this chapter for that individual.