Sec. 10.09.36.03. Conditions for Participation

A. To participate in the Program, the provider shall:

(1) Ensure compliance with all the Medical Assistance provisions listed in the Code of Maryland Regulations (COMAR) designated for their provider type;

(2) Apply for participation in the Program using the application form designated by the Department;

(3) Be approved for participation by the Department;

(4) Allow the Department or its agents to conduct unannounced on-site inspections of any and all provider locations;

(5) Allow the Department or its agents to require all providers to consent to criminal background checks, including fingerprinting;

(6) Have a current provider agreement with the Program in effect;

(7) Comply with all standards of practice, professional standards and levels of service as set forth in all applicable federal and State laws, statues, rules, and regulations as well as all administrative policies, procedures, transmittals, and guidelines issued by the Department;

(8) Charge the Program the provider’s customary charge to the general public for similar items or services. If the item or service is free to individuals not covered by Medicaid:

(a) The provider:

(i) May charge the Program; and

(ii) Shall be reimbursed in accordance with the Department’s rate provisions; and

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

(9) Maintain adequate records for a minimum of 6 years and make them available, upon request, to the Department or its designee;

(10) Accept payment by the Program as payment in full for covered services rendered and make no additional charge to any person for covered services;

(11) Provide services without regard to race, color, age, sex, national origin, religion, sexual orientation, gender identity, marital status, or physical or mental disability;

(12) Verify the recipient's eligibility by:

(a) Viewing the recipient's Medical Assistance card and another identification card; and

(b) Calling the Program's Eligibility Verification Interactive Voice Response System (EVS/IVR) or accessing the web-based recipient eligibility system;

(13) Place no restriction on a recipient's right to select health care providers of the recipient's choice, except that a participant in a managed care program shall be required to obtain certain specified Program services from or through the participant's care manager, in accordance with the restrictions imposed by the managed care program;

(14) Not knowingly employ or contract with a person, partnership, or corporation which has been disqualified from the Program to provide or supply services to Medical Assistance recipients unless prior written approval has been received from the Department;

(15) Notify the Department or its designee of patient activity or circumstance that affects placement, eligibility, or reimbursement, on the form and at the time specified by the Department;

(16) Maintain the confidentiality of all recipient information by not releasing the information without authorization by the recipient;

(17) Have an individual rendering number for practitioners recognized by the Program;

(18) Obtain a referral from a recipient's care manager in a manner prescribed by the Department before rendering services, when:

(a) The recipient is enrolled in a managed care program; and

(b) The service is included under the managed care program's referral requirements.

(19) Supply a signed service order or prescription that includes the individual rendering number of the ordering or prescribing practitioner, as well as the full name and Medical Assistance number of the recipient, when ordering services to be supplied by other providers, such as hospital admission, diagnostic testing, supplies, or pharmacy services:

(20) Ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed; and

(21) Provide a recipient's medical records at no charge when the records are requested by another physician or licensed provider on behalf of the recipient.

B. A provider may not seek payment from more than one State agency for the same service.

C. If the Program denies payment or requests repayment on the basis that an otherwise covered service was not medically necessary or preauthorized, the provider may not seek payment for that service from the recipient.

D. If the Program denies payment due to late billing, payment from the recipient may not be sought.

E. The Program may pay for a covered service rendered by a provider to a recipient under any of the following circumstances:

(1) The provider charges for nonrecipients who receive the same service by:

(a) Charging the individual in full for services rendered;

(b) Using a sliding fee scale based on the individual's income;

(c) Waiving all or part of the fee for a specific individual; or

(d) Agreeing to accept what a third party pays as payment in full, whether or not the provider bills individuals who lack this coverage;

(2) The State, using its own funds, pays for services rendered to a targeted group of nonrecipients, and the provider charges nontargeted users of the services;

(3) The provider bills all individuals with third party coverage, whether or not the provider bills individuals who lack this coverage;

(4) The service is offered by or through the State agency which administers the program of services authorized under Title V of the Social Security Act; or

(5) The service is offered to a handicapped child receiving services under the Education for the Handicapped Act (EHA) under an individualized education plan (IEP).

F. The following types of providers shall comply with the requirements of 42 CFR Part 489, Subpart I, Advance Directives:

(1) Acute hospitals under COMAR 10.09.92;

(2) Chronic hospitals under COMAR 10.09.93;

(3) Special pediatric hospitals under COMAR 10.09.94;

(4) Special psychiatric hospitals under COMAR 10.09.95;

(5) Nursing facilities under COMAR 10.09.10 and COMAR 10.09.11;

(6) Home health agencies under COMAR 10.09.04;

(7) Personal care case monitors under COMAR 10.09.20;

(8) Model waiver nursing services providers under COMAR 10.09.27; and

(9) Hospices under COMAR 10.09.35.