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<regulation prefix="Regulation" num=".05" citation="COMAR 10.09.02.05" title_num="10" subtitle_num="09" chapter_num="02" heading="Limitations.">
  <paragraph num="A.">
    <text>Services which are not covered are:</text>
    <paragraph num="(1)">
      <text>Physician services not medically justified;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Nonemergency dialysis services related to chronic kidney disorders unless they are provided in a Medicare-certified facility;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Physician inpatient hospital services rendered during any period that is in excess of the length of stay authorized by the Utilization control agent (UCA);</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Physician services denied by Medicare as not medically necessary;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Services which are investigational or experimental;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Autopsies;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Physician services included as part of the cost of an inpatient facility, hospital outpatient department, or free-standing clinics;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Payment to physicians for specimen collections, except by venipuncture, and capillary or arterial puncture;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Injectable medications, and visits solely for the administration of injectable medications, unless medical necessity and the patient’s inability to take appropriate oral medications are documented in the patient’s medical records;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Vaccine administration unless covered under Regulation .04 of this chapter;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Visits solely to accomplish one or more of the following:</text>
      <paragraph num="(a)">
        <text>Prescription, drug or food supplement pick-up, collection of specimens for laboratory procedures,</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Recording of an electrocardiogram,</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Ascertaining the patient's weight;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(12)">
      <text>Interpretation of laboratory tests or panels;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Medical Assistance prescriptions and injections for central nervous system stimulants and anorectic agents when used for weight control;</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Drugs and supplies dispensed by the physician which are acquired by the physician at no cost;</text>
    </paragraph>
    <paragraph num="(15)">
      <text>Disposable medical supplies;</text>
    </paragraph>
    <paragraph num="(16)">
      <text>Services prohibited by the Board of Physician Quality Assurance;</text>
    </paragraph>
    <paragraph num="(17)">
      <text>Services which are provided outside the United States;</text>
    </paragraph>
    <paragraph num="(18)">
      <text>Services which do not involve direct patient contact;</text>
    </paragraph>
    <paragraph num="(19)">
      <text>Sterilization reversal procedures;</text>
    </paragraph>
    <paragraph num="(20)">
      <text>Prescriptions for drugs written on prescription pads that do not prevent copying, modification, or counterfeiting;</text>
    </paragraph>
    <paragraph num="(21)">
      <text>Physician-administered drugs from manufacturers that do not participate in the Federal Drug Rebate Program; and</text>
    </paragraph>
    <paragraph num="(22)">
      <text>Any covered service that requires a preauthorization, including physician-administered drugs and injectable medications, that is rendered without an approved preauthorization from the Program.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Preoperative evaluations for anesthesia are included in the fee for administration of anesthesia and the provider may not bill them as consultations.</text>
  </paragraph>
  <paragraph num="C.">
    <text>Referrals from one physician to another for treatment of specific patient problems may not be billed as consultations.</text>
  </paragraph>
  <paragraph num="D.">
    <text>The operating surgeon may not bill for the administration of anesthesia or for an assistant surgeon who is not in the operating surgeon's employ.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Payment for consultations provided in a multispecialty setting is limited by criteria established by the Department.</text>
  </paragraph>
  <paragraph num="F.">
    <text>The Department will not pay a provider for those laboratory or x-ray services performed by another facility. The Department will pay directly the facility performing those services.</text>
  </paragraph>
  <paragraph num="G.">
    <text>The Program does not cover services rendered to an inpatient before one preoperative inpatient day, unless preauthorized by the Program.</text>
  </paragraph>
  <paragraph num="H.">
    <text>The provider may not bill the Program for services rendered under the supervising physician's provider number by an employed nonphysician extender, such as:</text>
    <paragraph num="(1)">
      <text>A physical therapist;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>An occupational therapist;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A speech language pathologist;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>An audiologist; or</text>
    </paragraph>
    <paragraph num="(5)">
      <text>A nutritionist.</text>
    </paragraph>
  </paragraph>
  <paragraph num="I.">
    <text>Services not rendered in-person shall comply with the telehealth requirements established in COMAR 10.09.49 and any other subregulatory guidance issued by the Department.</text>
  </paragraph>
</regulation>