Sec. 10.09.48.08. Payment Procedures

A. Request for Payment.

(1) Requests for payment for the services covered under this chapter shall be submitted by an approved provider according to procedures set forth in COMAR 10.09.36.04.

(2) Billing time limitations for services covered under this chapter are the same as those set forth in COMAR 10.09.36.06.

B. Payment Rates.

(1) Providers shall be reimbursed within 45 business days of approved invoice for services rendered based on the rates set forth in §C(1) and (2) of this regulation.

(2) For a comprehensive assessment, providers shall be reimbursed $450 per assessment.

(3) For all other services, providers shall be reimbursed:

(a) $17.54 per unit of service from July 1, 2013 through June 30, 2014;

(b) $14.63 per unit of service from July 1, 2014 through July 2, 2014;

(c) $16.59 per unit of service from July 3, 2014 through December 31, 2014;

(d) $16.88 per unit of service from January 1, 2015 through June 30, 2015;

(e) $17.39 per unit of service from January 1, 2016 through June 30, 2016;

(f) $17.99 per unit of service from July 1, 2016 through June 30, 2017;

(g) $18.61 per unit of service from July 1, 2017 through June 30, 2018;

(h) $19.26 per unit of service from July 1, 2018 through June 30, 2019; and

(i) $19.93 per unit of service thereafter.

C. Changes in Rates.

(1) The rates are subject to the limitations of the State budget.

(2) The rates may be changed on July 1 of each year beginning July 1, 2015, based on legislative action, and subject to limitations of the State budget.

(3) The annual inflationary cost adjustment for providers may not exceed a maximum adjustment of 4 percent.

D. Payment Limitations.

(1) Payment shall be made only to one approved provider for covered services rendered to a participant on a particular date of service.

(2) Payment for the services covered under this chapter:

(a) Shall be considered as payment in full; and

(b) May not supplement or be supplemented by payment from other sources, such as the participant, family, a public program, or private agency.

(3) For a comprehensive assessment, only one assessment may be reimbursed per participant, unless otherwise authorized by DDA.

(4) Ongoing coordination of community services shall be billed on a monthly basis.

E. Units of Services and Limitations.

(1) Provider will receive a pre-authorization of a specified number of units to be used for all of their clients.

(2) All coordination of community services other than the initial comprehensive assessment shall be billed to DDA in units of service.

(3) DDA shall provide payment for only those coordination of community services that were authorized by DDA before the provision of the service.

(4) Each fiscal year, DDA shall authorize a specific number of units of service of coordination of community services for each participant.

(5) Each fiscal year, the coordinator of community services shall complete the core services for each participant, using the units of service authorized for that fiscal year.

(6) Additional units of service may not be authorized beyond those authorized for the fiscal year for any participant, except as specifically provided in §E(6) of this regulation.

(7) Authorization of Payment for Additional Units of Service.

(a) A request by a coordinator of community services for authorization of payment for units of service in addition to those authorized for a participant in a single fiscal year may not be granted except in extraordinary circumstances.

(b) In deciding a request for authorization of payment for additional units of service, DDA shall consider:

(i) The services provided to date using the annual units of service authorized;

(ii) The extent to which the core services have been completed for the fiscal year;

(iii) Whether and, if so, the extent to which, the annual units of service were used to provide services other than core services;

(iv) The extent to which services were provided in an inefficient manner;

(v) Any unusual or unforeseeable needs of the participant that created a need for more than the allotted units of service; and

(vi) Any unusual or unforeseeable circumstances of the participant that caused the delivery of coordination of community services to be more difficult and time-consuming than was anticipated when the annual units of service were allotted.

(c) Requests for authorization of payment for additional units of service for a participant in a single fiscal year shall be accompanied by documentation demonstrating:

(i) All coordination of community services provided to date;

(ii) Any physical, emotional, or mental conditions of the participant that created extraordinary challenges to the provision of coordination of community services within the units of service authorized for the fiscal year; and

(iii) Any unusual or unforeseeable circumstances that required the expenditure of more time to provide the core services than was anticipated when the annual units of service were allotted.

(d) A request for authorization of payment for additional units of service for a participant in a single fiscal year may not be granted in order to provide services other than core services.

(e) A request for authorization of payment for additional units of service for a participant in a single fiscal year may not be considered unless all required data regarding the participant and the coordination of community services provided has been entered or uploaded into the DDA-designated data system.

(f) An authorization of payment for additional units of services shall specify the number of units of service authorized.