Sec. 10.09.94.09. Billing and Reimbursement Principles

A. The Program shall pay room and board charges for the day of admission, and may not pay room and board charges for the day of discharge from the hospital.

B. The provider shall submit a request for payment according to procedures designated by the Department.

C. Payments of Medicare Claims.

(1) Payment of Medicare claims is authorized if:

(a) The provider accepts Medicare assignment;

(b) Medicare makes direct payment to the provider;

(c) Medicare determined that services were medically necessary;

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

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

(2) Payment of a deductible and co-insurance related to Medicare claims 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 deductible and co-insurance shall be paid in full.

D. Out-of-State Hospital Reimbursement.

(1) The Program shall reimburse hospitals outside of Maryland, excluding the District of Columbia, 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 for overpayments, in accordance with Regulation .10 of this chapter.

E. Payment for Administrative Days.

(1) The provider shall document, on forms designated by the Department, information that satisfies the conditions stated in Regulation .06C of this chapter.

(2) The provider shall:

(a) Receive determination from the Department or its designee that the participant no longer requires the level of care that the special pediatric hospital is licensed to provide;

(b) Receive determination from the Department or its designee that the participant requires services at a lower level of acuity, and a bed in an appropriate facility is not available; and

(c) Notify the Department or its designee of discharge planning before the termination of the need for inpatient hospitalization at the level the facility is licensed to provide, and obtained a level of care determination from the agent.

F. During the period of administrative days, the Department or its designee shall review the documentation in increments of not more than 14 days.

G. For participants who are not ventilator-dependent, payment for approved administrative days shall be the lesser of:

(1) An estimated Statewide average Medicaid nursing home payment rate as determined by the Department; or

(2) If the hospital has a unit which is a skilled nursing facility, the allowable costs in effect under Medicare or extended services provided to participants of the unit.

H. The Department will make no direct payment to the participant.

I. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06.

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

K. Noncompliance with the Program’s requirements as determined by the Department or its designee shall result in nonpayment of the claim.

L. Payment on claims to a hospital located in the District of Columbia shall be reduced by a quarterly claims processing fee of 6 percent.