Sec. 10.09.92.07. Payment Procedures

A. Reimbursement Principles for Acute Hospitals Located in Maryland.

(1) The Department will make no direct reimbursement to any State-operated hospital. The Department will claim federal fund recoveries from the U.S. Department of Health and Human Services for services to participants in State-operated hospitals.

(2) Except for administrative days, acute hospitals shall be reimbursed at the rate set for the Program by the HSCRC pursuant to COMAR 10.37.10 or allowed under COMAR 10.37.03.

(3) If the Program discontinues using rates which have been approved by HSCRC, the Program shall reimburse providers:

(a) According to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413; or

(b) On the basis of charges if less than reasonable cost.

(4) The Department may not reimburse for the services of a hospital’s salaried or contractual clinical staff as a separate line item. Charges for these services should be included in the room and board rate or the appropriate ancillary service only, when HSCRC has included these salaries in the hospital’s costs.

(5) The Program shall reimburse room and board charges from the day of admission up to, but not including, the date of discharge from the hospital.

(6) The provider shall submit a request for payment according to procedures established by the Department.

(7) The Program reserves the right to return to the provider any invoice that is not properly completed.

(8) Payments on Medicare claims are authorized if:

(a) The provider accepts Medicare assignment;

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

(c) Medicare determined that services are medically necessary;

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

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

(9) The Department shall make a supplemental payment on Medicare claims as follows:

(a) Deductible and co-insurance shall be paid in accordance with the limits of this regulation; and

(b) Hospitals shall be paid subject to the HSCRC discounts, except in the case of a participant receiving hospital services in an out-of-State facility, in which case the deductible and co-insurance shall be paid in full.

(10) The provider shall not bill the Department or participant for:

(a) Completion of forms and reports;

(b) Broken or missed appointments;

(c) Services rendered by mail, telephone, or otherwise not in person, with the exception of telehealth services in accordance with COMAR 10.09.49; and

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

(11) Billing time limitations are set forth in COMAR 10.09.36.06.

(12) Freestanding medical facilities are reimbursed by the Department at the rate set for the freestanding facility by HSCRC.

B. Reimbursement Principles for Out-of-State Hospitals.

(1) For hospitals outside of Maryland, excluding the District of Columbia, claims reflecting dates of service on or after October 1, 2009, shall be reimbursed at a rate that is 100 percent of the amount reimbursable by the host state’s Title XIX agency or the amount of the hospital’s actual charges in total, whichever is less.

(2) Out-of-State providers are responsible for reimbursing the Department or its designee for overpayments, in accordance with COMAR 10.09.36.07.

C. Reimbursement Principles for Administrative Days.

(1) The hospital shall be paid for administrative days that are requested at the time of retrospective review and that are authorized by the Department or its designee after review of the:

(a) Clinical documentation;

(b) Discharge plan indicating that the hospital was seeking placement for the participant on the administrative days requested; and

(c) Documentation that was submitted to the Department on the authorized form that shows placement activity occurred on each day claimed as an administrative day.

(2) To be paid for administrative days, for participants who are not ventilator dependent, the reimbursement amount shall be an estimated Statewide average of the Program nursing home payment rate as determined by the Department.

(3) A hospital is not eligible for administrative day reimbursement if the days have already been billed as acute days.

D. Reimbursement Principles for Freestanding Acute Rehabilitation Hospitals. For freestanding acute rehabilitation hospitals not approved by the Program for reimbursement according to HSCRC rates, the Department shall reimburse these hospitals using a prospective payment system.