# COMAR Title 10 — Maryland Department of Health

## Subtitle 01 — Procedures

### Chapter 10 — Payment for Off-Grounds Medical Services

**Authority:** Health General Article, §2-104(b), Annotated Code of Maryland

**Administrative History:** Effective date:

**Administrative History:** Regulations .01—.07 adopted as an emergency provision effective September 1, 1983 (10:20 Md. R. 1780); adopted permanently effective December 19, 1983 (10:25 Md. R. 2268)

**Administrative History:** Regulation .02B amended effective February 20, 1989 (16:3 Md. R. 342)

**Administrative History:** Regulation .04D amended effective February 20, 1989 (16:3 Md. R. 342)

**Administrative History:** Chapter revised effective December 20, 1993 (20:25 Md. R. 1946)

#### Regulation .01 Purpose.

*COMAR 10.01.10.01*

The Secretary of Health (MDH) has established accounts for the purpose of payment of off-grounds medical services. These accounts are to be used by MDH facilities whose clients receive services from private medical providers that the facility cannot furnish or secure by contract. The care could include laboratory work, services from medical specialties, and acute hospitalization. The care does not include ambulance transportation.

#### Regulation .02 Definitions.

*COMAR 10.01.10.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Client” means a resident or patient in a Maryland Department of Health facility.

  (2) “Department” means the Maryland Department of Health.

  (3) Facility.

    (a) “Facility” means an inpatient or residential facility owned and operated by the Department.

    (b) “Facility” includes Mental Administration institutions, Developmental Disabilities Administration institutions, and chronic and rehabilitation facilities.

  (4) “Medical providers” means private providers of medical care or related services who render care to clients of the Department's facilities.

  (5) “Off-grounds medical services” means medical care or related services provided to clients of the Department's facilities rendered by medical providers at a site other than the facility.

  (6) “Secretary” means the Secretary of Health.

#### Regulation .03 Requirements.

*COMAR 10.01.10.03*

A. All facilities shall provide or arrange for the provision of medical care required by individuals placed in Department facilities.

B. All facilities shall purchase medical services that cannot be provided in the facility by the facility's staff or visiting consultants from providers appropriately licensed in the state in which the service is to be rendered.

C. All facilities shall purchase medical services from medical providers who agree to invoice the facility only for those services that are not covered by third-party payers, including federal, state, or federal-state programs.

D. The financial agents shall assist the provider in identifying potential sources of recovery.

#### Regulation .04 Payment Procedures.

*COMAR 10.01.10.04*

A. Medical providers shall collect to the extent possible from third-party payers such as Medical Assistance, Medicare, and private insurers.

B. Facilities shall direct medical providers to invoice the facility for the cost of those services not covered by third-party payers. For Medical Assistance recipients, the Secretary or the Secretary's designee shall determine which services are specifically provided for in the facility's budget and are included in the facility's Medical Assistance per diem rate, and, therefore, may not be billed directly to the Maryland Medical Assistance Program.

C. The purchase of care agreement entered into with the provider shall state that “The provider, in accepting this client for care, agrees to pursue recovery of the cost of care from all third-party payers and any state, federal, and federal-state program for which this client might be eligible, based on the information furnished by the facility before invoicing (name of facility).”

D. Payment in Full.

  (1) If a third-party source of payment is intended to be payment in full, the facility may accept but may not pay invoices for the service rendered, unless payment by the third-party source is denied.

  (2) If a third-party source of payment is not intended to be payment in full, the facility shall pay the amount of the bill not paid by the third-party payer.

E. Medical providers shall submit all invoices to the appropriate facility within 12 months of the date of services.

#### Regulation .05 Recovery and Reimbursement.

*COMAR 10.01.10.05*

A. If a client has insurance or if any other person is obligated, either legally or contractually, to pay for, or to reimburse the client for any service covered by this chapter, the medical provider shall seek payment from that source.

B. Payment. If payment is made by both the facility and insurance or other payer, the following conditions apply:

  (1) If the facility has paid all or part of the invoice and the third-party payer has made payment that represents payment in full, then the medical provider shall return the facility's entire payment to the facility;

  (2) If the facility has paid the invoice in full and if the third-party payer has made payment that represents partial payment, then the medical provider shall return the amount of the third-party payment to the facility;

  (3) If a third-party payer has made payment that is intended to be a partial payment and the facility has paid the remainder, then no repayment to the facility is required.

C. The provider shall reimburse the facility for any overpayment.