<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".06" citation="COMAR 10.09.01.06" title_num="10" subtitle_num="09" chapter_num="01" heading="Payment Procedures.">
  <paragraph num="A.">
    <text>The provider shall submit the request for payment in the format designated by the Department.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The Department reserves the right to return to the provider, before payment, all requests for payment not properly completed.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The provider shall charge the Program the provider's:</text>
    <paragraph num="(1)">
      <text>Customary charge to the general public for similar services; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Acquisition cost for injectable drugs or dispensed medical supplies.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>The provider shall be paid the lesser of:</text>
    <paragraph num="(1)">
      <text>The provider's customary charge to the general public unless the service is free to individuals not covered by the Program; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The Program rates as described in COMAR 10.09.02.07.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>If a service is free to individuals not covered by the Program:</text>
    <paragraph num="(1)">
      <text>The provider:</text>
      <paragraph num="(a)">
        <text>May charge the Program; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Shall be reimbursed in accordance with §D of this regulation; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The provider's reimbursement is not limited to the provider's customary charge.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>Payments on Medicare claims are authorized, if:</text>
    <paragraph num="(1)">
      <text>Services are covered by the Program;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The provider accepts Medicare assignments;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Medicare makes direct payment to the provider;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Medicare has determined that services were medically justified; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Initial billing is made directly to Medicare according to Medicare guidelines.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>The Department shall make supplemental payments on Medicare claims subject to the following provisions:</text>
    <paragraph num="(1)">
      <text>Deductible insurance shall be paid in full; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Coinsurance shall be paid at the lesser of:</text>
      <paragraph num="(a)">
        <text>100 percent of the coinsurance amount; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The balance remaining after the Medicare payment is subtracted from the Program rate.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>The provider may not bill the Program for:</text>
    <paragraph num="(1)">
      <text>Completion of forms and reports;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Broken or missed appointments; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Professional services rendered by mail.</text>
    </paragraph>
  </paragraph>
  <paragraph num="I.">
    <text>The Program may not make direct payment to participants.</text>
  </paragraph>
  <paragraph num="J.">
    <text>Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.</text>
  </paragraph>
  <paragraph num="K.">
    <text>The Program shall reimburse for all medical laboratory services according to the fees established under COMAR 10.09.09.</text>
  </paragraph>
  <paragraph num="L.">
    <text>An advanced practice nurse who is employed by or under contract to any physician, clinic, or hospital may not bill for any service for which reimbursement is sought by the physician, clinic, or hospital.</text>
  </paragraph>
  <paragraph num="M.">
    <text>The Program may not reimburse nurse midwives for prenatal or postpartum care once the patient has been referred to a physician for completion of prenatal or postpartum care.</text>
  </paragraph>
</regulation>