Sec. 10.09.80.06. Limitations

A. The Program under this chapter does not cover the following:

(1) Community-based substance use disorder services not specified in Regulation .05 of this chapter;

(2) Community-based substance use disorder services not approved by a licensed physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law;

(3) Services not identified by the Department as medically necessary or listed in Regulation .05 of this chapter;

(4) Investigational and experimental drugs and procedures;

(5) Substance use disorder visits solely for the purpose of:

(a) Prescribing medication;

(b) Administering medication;

(c) Drug or supply pick-up;

(d) Collecting laboratory specimens;

(e) Interpreting laboratory tests or panels; or

(f) Administering injections, unless the following are documented in the participant’s medical record:

(i) Medical necessity; and

(ii) The participant’s inability to take appropriate oral medications;

(6) Services that are provided in a hospital inpatient or outpatient setting or in an intermediate care facility for behavioral health;

(7) Services beyond the provider’s scope of practice;

(8) Services that are separately billed but included as part of another service;

(9) Buprenorphine induction and buprenorphine maintenance therapy services that are:

(a) Delivered by a participant’s primary care provider which are the responsibility of the Managed Care Organization as specified in COMAR 10.67.08; or

(b) Delivered without a primary diagnosis of substance use disorder; and

(10) Services not authorized consistent with this chapter.

B. Providers may not be reimbursed by the Program for:

(1) More than one comprehensive substance use disorder assessment for a participant per provider per 12-month period unless there is a break in treatment over 30 calendar days;

(2) More than one Level 1 group counseling session per day per participant;

(3) More than six Level 1 individual counseling units as measured in 15 minute increments per day per participant;

(4) More than four sessions of Level 2.1 Intensive Outpatient treatment per week;

(5) Level 1 group or individual counseling during the same week as a Level 2.1 Intensive Outpatient treatmentor Level 2.5 Partial Hospitalization service unless the participant has been discharged from or admitted to a new level of care;

(6) Overlapping episodes of Level 2.1 Intensive Outpatient treatment and Level 2.5 Partial Hospitalization;

(7) Level 1 group or individual counseling during the same week as Level 1 group or individual counseling offered by another provider;

(8) Psychiatric day treatment service as described in COMAR 10.09.02.01 or an intensive outpatient mental health service on the same day as a Level 2.1 Intensive Outpatient program or Level 2.5 Partial Hospitalization program;

(9) Buprenorphine maintenance therapy delivered by an opioid treatment program or an OHCQ certified or licensed substance use disorder treatment provider during the same week as Methadone Maintenance Therapy;

(10) Ambulatory withdrawal management during the same week as an opioid maintenance therapy, medication assisted treatment induction, or buprenorphine maintenance service;

(11) Medication management billed by an opioid treatment program or an OHCQ certified or licensed substance use disorder treatment provider during the same days as medication assisted treatment induction;

(12) Community-based substance use disorder services on the same day that a participant received similar services as a hospital inpatient or outpatient;

(13) Services delivered by federally qualified health centers other than those billed using T-codes that may include the following delivered by two separate appropriately licensed providers:

(a) One T-code for mental health services per day with associated mental health procedure code; and

(b) One T-code for substance use disorder services with associated H-code per day;

(14) Services rendered but not appropriately documented to the level of service;

(15) Services rendered by mail, telephone, or otherwise not one-to-one, in person;

(16) Completion of forms or reports;

(17) Broken or missed appointments; and

(18) Travel to and from site of service.

C. In order to bill for an individual in Level 2.1 Intensive Outpatient treatment, the per diem session shall include a minimum of 2 hours. A maximum of 4 per diems may be billed per week.

D. In order to bill for an individual in Level 2.5 Partial Hospitalization, the per diem rate for a half day session shall include a minimum of 2 hours.

E. In order to bill for an individual in Level 2.5 Partial Hospitalization, the per diem rate for a full day session shall include a minimum of 6 hours.

F. The Department shall pay participating opioid treatment programs, per participant, per week provided the participant received ongoing opioid treatment medications and at least one face-to-face documented treatment service in the month for which the Program is billed.

G. In order for an opioid treatment program to bill for medication assisted treatment induction, the provider shall bill this service only in the first week of treatment per participant or in the first week of treatment after a break from treatment of at least 6 months.

H. In order for an opioid treatment program to bill for buprenorphine maintenance therapy, the provider shall bill this service per participant per week.

I. In order to bill for ambulatory withdrawal management, providers may bill up to 5 per diems during the detoxification episode if determined medically necessary by the Department.

J. All drug screening lab claims submitted to the ASO by providers other than opioid treatment programs shall list the applicable substance use disorder diagnosis.