Md. Code Regs. 10.09.59.07

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.59.07 - Limitations

The Program does not cover the following:

A. Services not delivered in compliance with the COMAR references listed in Regulations .04 and .05 of this chapter;

B. Services not medically necessary;

C. Investigational or experimental drugs and procedures;

D. Specialty mental health services for participants in an institution for mental disease as defined in 42 CFR § 435.1009 unless the service is delivered through the Medicaid Emergency Psychiatric Demonstration;

E. Specialty mental health visits solely for the purpose of:

(1) Prescribing medication;

(2) Administering medication;

(3) Drug or supply pick-up;

(4) Collecting laboratory specimens;

(5) Interpreting laboratory tests or panels; or

(6) Administering injections, unless the following are documented in the participant's medical record:

(a) Medical necessity; and

(b) The participant's inability to take appropriate oral medications;

F. Separate reimbursement to an employee of a program for services that have been provided by and reimbursed directly to a program;

G. Vocational counseling, vocational training at a classroom or job site, and academic or remedial educational services;

H. Services provided to or for the primary benefit of individuals other than the participant;

I. Outpatient Mental Health Clinic services delivered to a participant with a primary diagnosis of substance use disorder, unless the claim reflects a secondary diagnosis of mental health;

J. An on-site psychiatric rehabilitation program visit by a participant on the same day that the participant receives medical day care services under COMAR 10.09.07;

K. Telehealth services other than those services that are specified in COMAR 10.09.49;

L. Non-emergency services not authorized by the ASO;

M. Mental health services delivered by a primary care provider and reimbursed through Medicaid Fee for Service or the Maryland Medicaid Managed Care Program;

N. Services delivered by Federally Qualified Health Centers other than those billed using the T-code, which may include the following, delivered by two separate but appropriately licensed providers:

(1) One T-code for mental health services per day; and

(2) One T-code for substance use disorder services per day;

O. Supported employment services provided by a community-based psychiatric rehabilitation program, except in cases of clinic coordination;

P. Residential crisis services;

Q. Respite care services, other than those provided through the 1915(i) Intensive Behavioral Health Services program described in COMAR 10.09.89;

R. Services provided to participants in a hospital inpatient setting, with the exception of services delivered by:

(1) Physicians; and

(2) Nurse Practitioners;

S. Housing services;

T. Services rendered but not appropriately documented;

U. Services reimbursed by the ASO not included in this chapter;

V. Mobile Treatment or ACT Services without a minimum of four in-person services provided per month;

W. Services rendered by community based specialty mental health programs with an immediate family member of an employee of the program serving on the governing body, board of directors, or advisory committee, whichever applies; and

X. Psychiatric rehabilitation services referred by:

(1) An individual who is not enrolled as a provider in the Program with an active status on the date of service; and

(2) An entity, facility, or another provider that is not an individual.

Md. Code Regs. 10.09.59.07

Regulations .07 adopted as an emergency provision effective February 3, 1995 (22:4 Md. R. 232); adopted permanently effective June 5, 1995 (22:11 Md. R. 821)
Regulations .07 amended as an emergency provision effective July 1, 1997 (24:18 Md. R. 1291); emergency status expired December 31, 1997; amended permanently effective February 9, 1998 (25:3 Md. R. 144)
Regulation .07K-M amended effective August 10, 1998 (25:16 Md. R. 1274)
Regulations .07 under, Rehabilitation and Other Mental Health Services, repealed and new Regulations .07 under, Specialty Mental Health Services, adopted effective December 22, 2014 (41:25 Md. R. 1479)
Regulation .07 amended effective 42:21 Md. R. 1300, eff.10/26/2015; amended effective 45:8 Md. R. 420, eff. 4/23/2018; amended effective 45:26 Md. R. 1243, eff. 12/31/2018