Sec. 10.09.76.07. Payment Procedures

A. The provider shall submit a completed request for payment in the format designated by the Department or HealthChoice MCO, including required documentation.

B. The dental provider shall submit a request for payment in the format designated by the Department and in accordance with COMAR 10.09.05.07.

C. The Program reserves the right to return to the provider, before payment, all invoices not properly completed.

D. Unless the service is free to individuals not covered by Medicaid, a provider shall bill the Program the provider’s customary charge to the general public for similar services.

E. The Department shall authorize payment on Medicare cross-over claims only if:

(1) The provider accepts Medicare assignments;

(2) Medicare makes a direct payment to the provider;

(3) Medicare determines the services are medically necessary;

(4) The services are covered by the Program; and

(5) Initial billing is made directly to Medicare according to Medicare guidelines.

F. The Department shall make supplemental payment on Medicare cross-over claims subject to the following provisions:

(1) A deductible shall be paid in full;

(2) Coinsurance shall be paid at the lesser of:

(a) 100 percent of the coinsurance amount; or

(b) The balance remaining after the Medicare payment is subtracted from the Medicaid rate;

(3) Services not covered by Medicare, but considered medically necessary by the Program, shall be paid according to the limitations of this chapter; and

(4) Coinsurance shall be paid in full to FQHC providers.

G. An SBHC providing self–referred services as described in COMAR 10.67.06.28 to an MCO participant shall:

(1) Verify eligibility and MCO assignment through EVS on the day of service;

(2) Submit claims within 180 days of performing the service;

(3) Submit claims using the CMS 1500 for paper processing and the HIPAA compliant 837P for electronic processing; and

(4) Bill third party insurers before billing the MCO with the exception of well-child care and immunizations.

H. The provider may not bill the Program for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) More than one visit to complete an EPSDT screen; and

(4) Providing a copy of a participant’s medical record when requested by another licensed provider on behalf of the participant.

I. The Program may not make direct payment to participants.

J. The Program may not make a separate direct payment to any individual employed by or under contract to any SBHC for services provided in an SBHC.

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