Md. Code Regs. 10.48.01.07

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.48.01.07 - Payment Procedures

A. The provider shall submit the request for payment on the appropriate Medical Assistance Program invoice form.

B. The Department reserves the right to return to the provider, before payment, all invoices not properly signed, completed, and accompanied by properly completed forms required by the Department.

C. Providers shall charge the Program their usual and customary charge to the general public for similar services.

D. The fee schedule for covered services except hospital services shall be the same as is contained in the Maryland Medical Assistance Program's Professional Services Provider Manual and Fee Schedule which is incorporated by reference in COMAR 10.09.02.0 7D.

E. The reimbursement rates for all covered hospital services shall be the Health Services Cost Review Commission approved rates less the discount allowed the Medical Assistance Program.

F. For covered services, the Program shall pay the lower of:

(1) The provider's usual and customary charge to the general public for similar services; or

(2) The applicable rate described in §D or E of this regulation.

G. Supplemental payment on Medicare claims shall be made by the Program subject to the following provisions:

(1) Deductible insurance shall be paid in full;

(2) Coinsurance shall be paid in full;

(3) Services not covered by Medicare are payable according to §F of this regulation.

H. Payments on Medicare claims shall be authorized if:

(1) The provider accepts Medicare assignments;

(2) Medicare makes direct payment to the provider;

(3) Services are covered by the Program;

(4) Initial billing is made directly to Medicare according to Medicare guidelines.

I. The provider may not bill the Program for:

(1) Completion of forms and reports;

(2) Professional services rendered by mail or telephone;

(3) Services which are provided at no charge to the general public.

J. The Program shall make no direct payment to anyone except providers.

K. The Program may not reimburse invoices received for payment by the local department of social services more than 90 days after the date of service.

L. Providers shall bill the Program in the following manner:

(1) Claims shall be submitted on appropriate forms;

(2) Claims shall be submitted to the local department of social services and shall be received by that department within 90 days of the date of service;

(3) A claim which is rejected for payment due to improper completion or incomplete information shall be paid only if it is properly completed, resubmitted, and received by the Program within the original 90-day period or within 60 days of the rejection, whichever is later.

Md. Code Regs. 10.48.01.07

Amended effective 44:4 Md. R. 252, eff. 2/27/2017