Sec. 10.09.52.06. Payment Procedures

A. Request for Payment.

(1) An approved provider shall submit requests for payment for the services covered under this chapter according to procedures established by the Program. The Program reserves the right to return to the provider, before payment, all requests not properly completed.

(2) A provider shall:

(a) Bill the Program for the appropriate fee or fees specified in §C of this regulation;

(b) Accept payment from the Program as payment in full for the services covered under this chapter and make no additional charge to the participant or any other party; and

(c) Submit a request for payment in the manner specified by the Program, that includes the:

(i) Date or dates of service,

(ii) Participant's name and Medical Assistance number,

(iii) Provider's name, location, and identification number, and

(iv) Nature, unit or units, and procedure code or codes of covered services provided.

(3) Providers that convene or conduct an IEP team or teams in accordance with COMAR 13A.05.01 may bill the Program for all IEP-related services contained in this chapter.

(4) Providers that participate on, but do not convene or conduct, an IEP team or teams, may only bill for ongoing service coordination, only for day students. These providers may not bill for ongoing service coordination for the residential students who reside in facilities that receive Medical Assistance reimbursement for residential services.

(5) A waiver participant's provider of residential habilitation services under COMAR 10.09.56 may:

(a) Provide the waiver participant with waiver ongoing service coordination under Regulation .04-2B of this chapter;

(b) Not provide the waiver participant with a waiver initial assessment under Regulation .04-2A of this chapter or a waiver reassessment under Regulation .04-2C of this chapter.

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

C. The Program shall make payment only to one qualified provider for covered services rendered on a particular date of service to a participant and according to the following fee-for-services schedule covered under this chapter:

DescriptionFee Per Unit of Service

(1) Initial IEP: no more than one unit of service may be reimbursed per participant ... $500;

(2) Ongoing service coordination: no more than one unit of service per month may be reimbursed for a participant ... $150;

(3) IEP review: at most, three units of service may be reimbursed for a participant in a 12-month period ... $275;

(4) Waiver initial assessment: No more than one unit of service may be reimbursed per waiver participant ... $500;

(5) Waiver ongoing service coordination: No more than one unit of service per month may be reimbursed for a waiver participant ... $150;

(6) Waiver reassessment: At most, four units of service may be reimbursed for a waiver participant in a 12-month period ... $275.

D. The Program may not make payment for ongoing service coordination when, for the same month, payment is made to the provider for furnishing to the participant:

(1) An initial IEP service; or

(2) An IEP review service.

E. The Program may not make payment for more than one IEP review in the same month, unless a subsequent review is documented as an emergency.

F. The Program may not make payment for an initial IEP and an IEP review in the same month, unless a review is documented as an emergency.

G. If an IEP review takes more than one meeting to complete, the Program shall only make payment for the meeting during which the review was signed.

H. A provider shall be paid the lesser of:

(1) The provider’s usual and customary charge to the general public unless the service is free to individuals not covered by Medicaid; or

(2) The rate established under §C of this regulation.