Sec. 10.21.25.03-1. General Reimbursement Conditions

A. Claims Submission. In order to be reimbursed by the Department, an approved provider shall submit a claim when the provider has:

(1) Obtained authorization to provide the services for which the claim is being submitted;

(2) Delivered the service;

(3) Documented provision of service as required; and

(4) Complied with any regulatory preconditions for the delivery of the service.

B. Claims Retraction. The Department may retract any payments made to any PMHS provider for paid claims if an audit indicates that:

(1) The services were not provided;

(2) The services were not medically necessary;

(3) There is no documentation that the services were provided;

(4) The precondition for the delivery of the service was not met; or

(5) The provider failed to comply with §H of this regulation.

C. If the Department retracts funds from a provider under §B of this regulation, within 30 days following the retraction the Department shall provide notice and an opportunity for a hearing.

D. Limitations.

(1) The Department shall reimburse, for services delivered on the same service date for the same individual, an outpatient mental health center (OMHC) for a maximum of two therapy sessions subject to the following conditions:

(a) Only one may be an individual therapy session;

(b) Only one may be a group therapy session; and

(c) Only one may be a family therapy session, either with or without the individual.

(2) The Department may not reimburse an OMHC for the following services delivered to the same individual on the same service date:

(a) Individual therapy with medication management session, and medication management session;

(b) Diagnostic interview or assessment, and a treatment planning session; and

(c) A diagnostic interview or assessment, and a therapy session.

(3) For all other providers, the Department shall reimburse for only one service per service date.

(4) Limitations Exception. The Department may provide an exception to the limitation rule on outpatient services if the ASO finds that the service:

(a) Is medically necessary;

(b) Is not duplicative; and

(c) Has been preauthorized.

E. The Department shall reimburse Psychiatric Rehabilitation Program services provided to a child residing in a therapeutic group home, as defined in COMAR 10.21.07 when the TGH certifies that its negotiated rate does not include payment for the PRP services.

F. The Department may not reimburse outpatient mental health services provided to an individual when the individual is in a hospital or residential treatment center.

G. The Department may not reimburse PRP providers until the PRP has met the minimum service encounters as defined in Regulation .09 of this chapter.

H. For individual practitioners, when services are preauthorized, the following documentation is required before submitting for payment for services rendered:

(1) For each individual served, the medical record, which shall include the following documentation:

(a) A signed consent to treatment;

(b) A comprehensive assessment that includes the:

(i) Individual or family’s presenting problem;

(ii) Individual or family’s history;

(iii) Individual’s diagnosis; and

(iv) Rationale for the diagnosis; and

(c) An individualized treatment plan that includes the:

(i) Problems, needs, strengths, and goals that are measurable;

(ii) Interventions that are medically necessary; and

(iii) Signatures of the individual, or if the individual is a minor, the guardian, and the treating mental health professional; and

(2) Progress notes for each face-to-face contact including:

(a) Date of service;

(b) Start time and end time;

(c) Location;

(d) Summary of interventions provided; and

(e) The treating mental health professional’s signature and date of service.

I. Services rendered by an individual practitioner may only be reimbursed for the licensed mental health professionals authorized by the practice board to diagnose and treat psychiatric disorders as identified in this chapter of regulations.