Sec. 10.21.25.02. General Reimbursement

A. The Department shall reimburse the lower of the amount billed or the fee established under this chapter, after the application of an individual's copayment, based on the ability-to-pay determination according to Regulation .03 of this chapter.

B. The Department may reimburse for non-Medicaid-reimbursable mental health services to the extent that State resources permit.

C. According to the provisions of this chapter, the Department shall reimburse a mental health services provider:

(1) That is:

(a) A community-based mental health program that is approved by the Department; or

(b) An appropriately credentialed individual practitioner who contracts with the Department's Medical Assistance Program;

(2) For specific services that are delivered to:

(a) Medicaid recipients; or

(b) Individuals for whom, because of the severity of their mental illness and their financial need, the cost of mental health services is subsidized, in whole or in part, by State general funds for services not reimbursed under a grant or a contract.

D. This chapter does not establish fees for services that are provided by:

(1) A federally qualified health center;

(2) An inpatient facility regulated by the Health Services Cost Review Commission, to an inpatient or resident of the facility; or

(3) A home health agency licensed under COMAR 10.09.04.

E. The mental health service provider shall bill services using:

(1) The procedural terminology codes contained in the most current Physician's Current Procedural Terminology (CPT) manual published by the American Medical Association and incorporated by reference in COMAR 10.09.09.07D; and

(2) If there is no current CPT code for the service, a customized code published by the Administration.

F. The mental health service provider, by submitting a claim for reimbursement for service, certifies that the service is medically necessary, has been delivered and meets the description and intent of the CPT code which is contained on its claim for reimbursement.

G. Medicare Recipients.

(1) If a provider renders services to individuals who are Medicare recipients, the provider shall comply with all federal Medicare requirements.

(2) If a provider does not comply with all Medicare requirements, the provider may not seek reimbursement by the PMHS.