Sec. 10.25.10.07. Payments for Uncompensated Care Patients

A. A trauma physician:

(1) Is eligible for payment from the Fund for trauma services provided to uncompensated trauma care patients with an admission date on the Maryland Trauma Registry beginning on or after July 1, 2006; and

(2) May seek reimbursement in accordance with this regulation.

B. The cost of uncompensated care incurred by a trauma physician in providing trauma care to a trauma patient as defined in this chapter shall be reimbursed at a rate of up to 100 percent of the current Medicare facility-based payment for a service in the Baltimore carrier locality area, less any amount for trauma physician services paid by the patient or other third-party payors including, but not limited to, auto insurance, criminal injuries compensation fund, attorneys, or collection agencies, as reported to the Fund on the uncompensated services claim.

C. An organization billing on behalf of physicians eligible for uncompensated care payments shall:

(1) Designate a trauma service by appropriate coding of the CPT Modifier on the electronic ANSI 837 transaction or paper CMS 1500 claim in accordance with claims submission requirements; and

(2) Include the patient's trauma registry number on the electronic claim or on the CMS 1500.

D. Diagnosis Code.

(1) Except as provided in §D(2) of this regulation, a diagnosis code shall fall between 800.00-959.9.

(2) If a diagnosis code does not fall between 800.0-959.9, a supplementary classification of external causes of injury and poisoning (E800-E999) shall appear as a secondary diagnosis code.

E. To be eligible for uncompensated care differential payment described in §B of this regulation, the place of service code shall have one of the following values:

(1) Appropriate code for "acute care inpatient hospital";

(2) Appropriate code for "outpatient hospital";

(3) Appropriate code for "emergency room"; or

(4) Appropriate code for "rehabilitation hospital".

F. The uncompensated services claim shall:

(1) Document uncompensated care services not previously claimed under the Fund;

(2) Exclude services for trauma patients who have applied for assistance through Medicaid, but who have not received a final eligibility determination;

(3) Exclude noncovered services that the trauma physician provided to trauma patients covered by health insurance; and

(4) Exclude services for trauma patients covered by health insurance for which the physician failed to comply with the insurer's coverage rules or claim filing requirements.

G. Uncompensated care services are eligible for reimbursement from the Fund only after a faculty practice plan, a physician practice plan, a trauma center on behalf of a trauma physician, or an individual trauma physician has completed its collection efforts using the respective entity's documented policies and procedures.

H. Order of Preference.

(1) To minimize administrative costs in administering the Fund, the order of preference for the entity submitting an uncompensated services claim is as follows:

(a) Faculty practice plan;

(b) Physician practice;

(c) Trauma physician.

(2) The preference specified in §H(1) of this regulation refers to the submitting entity and not the preference for distributing payments.

I. A trauma patient treated at an out-of-State pediatric trauma center that has entered into an agreement with MIEMSS shall be a Maryland resident in order for the trauma physician to file an uncompensated services application for an uncompensated care shortfall payment. The determination of whether a trauma patient is a Maryland resident shall be based on the trauma patient's demographic information as listed on the Maryland Trauma Registry.

J. The uncompensated services claim shall contain the following information:

(1) The name and federal tax identification number of the trauma physician rendering the care;

(2) The date of the service;

(3) Appropriate codes describing the service;

(4) Any amount recovered for the service rendered;

(5) The name of the trauma patient;

(6) The trauma patient's Maryland Trauma Registry number;

7) Date of the original trauma injury;

(8) The diagnosis codes that were treated;

(9) The procedure and service codes performed; and

(10) Other information requested in the claim.

K. The Commission, in consultation with the Health Services Cost Review Commission, may establish a payment rate for uncompensated care incurred by a trauma physician in providing trauma care to trauma patients that is above the 100 percent of Medicare payment for the service if:

(1) The Commission determines that increasing the payment rate above 100 percent of the Medicare payment for the service will address an unmet need in the State trauma system;

(2) The source of revenue increases and the projected current uses of the Fund decline;

(3) The Commission considers data analyses of trauma care rendered at Maryland trauma centers for CPT codes reimbursed as uncompensated care as reported to the Maryland Medical Care Data Base; and

(4) The Commission reports on its intention to increase the payment rate to the Senate Finance Committee and the House Health and Government Operations Committee, at least 60 days before any adjustment to the rate.