Sec. 10.14.02.13. Freestanding Ambulatory Surgical Center Services

A. To be considered a participating freestanding ambulatory surgical center in the Program, the provider shall:

(1) Be Medicare certified to provide ambulatory surgical services in Maryland or a jurisdiction bordering Maryland;

(2) Comply with COMAR 10.09.42.02 and .03B;

(3) Agree to abide by the provisions set forth in this regulation by signing and sending to the Department the designated Departmental form;

(4) Agree to accept, as payment in full for the reimbursed service, the amount paid by the Program as specified in §E of this regulation plus, if applicable, the amount paid by the eligible patient's health insurer and the patient contribution amount;

(5) Agree not to bill an eligible patient, who is either uninsured or who is insured with Medicare only, for the reimbursed service;

(6) Agree not to bill an eligible patient, who has insurance coverage other than Medicare only, for an additional charge for the reimbursed service other than the patient contribution amount;

(7) Maintain adequate records for a minimum of 6 years and, upon request, allow the Department access to the records; and

(8) Agree to the medical requirements of the Program pursuant to Regulation .04A(8)-(10) of this chapter.

B. The Program shall reimburse a participating freestanding ambulatory surgical center for a service when the service:

(1) Complies with COMAR 10.09.42.04; and

(2) Is directly related to the diagnosis and treatment of breast cancer, cervical cancer, or a precancerous cervical lesion including, but not limited to, the following:

(a) Breast biopsy;

(b) Conization;

(c) Dilation and curettage;

(d) Laser treatment;

(e) Mastotomy; and

(f) Simple or partial mastectomy excluding modified radical mastectomy and radical mastectomy.

C. The Program does not reimburse for the following:

(1) A service that is not directly related to the diagnosis and treatment of breast cancer, cervical cancer, or a precancerous cervical lesion; and

(2) A service or procedure pursuant to COMAR 10.09.42.05.

D. A participating freestanding ambulatory surgical center shall:

(1) Accept and perform the responsibilities pursuant to Regulation .04E(1)-(7) and (9) of this chapter; and

(2) Submit a bill for the reimbursed service provided for an eligible patient on the form designated by the Department within 12 months of the date of service as follows:

(a) If an eligible patient is uninsured or has insurance that does not provide coverage for the reimbursed service, the participating freestanding ambulatory surgical center shall send the bill to the Department; or

(b) If an eligible patient is covered by Medicare or other insurance, the participating freestanding ambulatory surgical center shall bill:

(i) Medicare or the other insurance the composite rate for the service or procedure performed; and

(ii) The Department for the outstanding deductible and patient contribution amount.

E. The Department shall pay the participating freestanding ambulatory surgical center for a reimbursed service:

(1) Pursuant to COMAR 10.09.42.06A, B, D, and E for an eligible patient who is uninsured or has insurance that does not provide coverage for the reimbursed service;

(2) Pursuant to COMAR 10.09.42.06F for an eligible patient who is covered by Medicare; or

(3) The outstanding deductible and patient contribution amount required by the insurer for an eligible patient who has insurance, other than Medicare, that provides coverage for the reimbursed service.

F. The Program shall reimburse for claims submitted pursuant to this regulation as set forth in Regulation .21 of this chapter.