<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".07" citation="COMAR 10.09.02.07" title_num="10" subtitle_num="09" chapter_num="02" heading="Payment Procedures.">
  <paragraph num="A.">
    <text>The provider shall submit the request for payment on the form designated by the Department.</text>
  </paragraph>
  <paragraph num="B.">
    <text>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.</text>
  </paragraph>
  <paragraph num="C.">
    <text>Except as provided in §F of this regulation, the Provider shall charge the Program the provider’s customary charge to the general public for similar services. If the service is free to individuals not covered by Medicaid:</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="D.">
    <text>The Maryland Medical Assistance Program's procedures for payment are contained in the following documents, the provisions of which are incorporated by reference:</text>
    <paragraph num="(1)">
      <text>The Professional Services Provider Manual and Fee Schedule (Effective January 2024); and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The Medical Laboratories Fee Schedule pursuant to COMAR 10.09.09.07D.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Except as provided in §F of this regulation, the Department will pay for covered services at the lesser of:</text>
    <paragraph num="(1)">
      <text>Physician's customary charge or acquisition cost unless the service is free to individuals not covered by Medicaid; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The Department's fees in accordance with §D of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>The Program shall reimburse providers up to the acquisition cost for diagnostic and therapeutic radiopharmaceuticals, contraceptive products and devices, and injectable medications when the provider submits documentation indicating that the acquisition cost of the product, device, or drug is greater than the reimbursement allowed in §E of this regulation.</text>
  </paragraph>
  <paragraph num="G.">
    <text>The Program reserves the right to negotiate and establish a different fee for a physician or a group of physicians under contract to a hospital to provide services when a portion of the cost of the contract is paid as the hospital's cost, provided this fee does not exceed limitations set forth in §E of this regulation.</text>
  </paragraph>
  <paragraph num="H.">
    <text>Supplemental payments on Medicare claims are made subject to the following provisions:</text>
    <paragraph num="(1)">
      <text>Deductible insurance will be paid in full;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Beginning with August 1, 2010 dates of service, and subject to the limitations of the State budget, coinsurance, shall be paid:</text>
      <paragraph num="(a)">
        <text>In full for the following:</text>
        <paragraph num="(i)">
          <text>Mental health services;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>CPT codes that are priced by report;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Claims for anesthesia services;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Claims from a federally qualified health center; and</text>
        </paragraph>
        <paragraph num="(v)">
          <text>HCPCS codes beginning with A through W; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>For all other claims, at the lesser of:</text>
        <paragraph num="(i)">
          <text>100 percent of the coinsurance amount; or</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The balance remaining after the Medicare payment is subtracted from the Medicaid rate; and</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Services not covered by Medicare are payable according to §E of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="I.">
    <text>Payments on Medicare claims are authorized if the:</text>
    <paragraph num="(1)">
      <text>Provider accepts Medicare assignments;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Medicare makes direct payment to the provider;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Medicare has determined that services were medically justified;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Services are covered by the Program;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Initial billing is made directly to Medicare according to Medicare guidelines.</text>
    </paragraph>
  </paragraph>
  <paragraph num="J.">
    <text>The provider may not bill the Department or the participant for:</text>
    <paragraph num="(1)">
      <text>Completion of forms and reports;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Broken or missed appointments;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Professional services rendered by mail; or</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Providing a copy of a participant’s medical record when requested by another licensed provider on behalf of the participant.</text>
    </paragraph>
  </paragraph>
  <paragraph num="K.">
    <text>The Program will make no direct payment to participants.</text>
  </paragraph>
  <paragraph num="L.">
    <text>The Program will reimburse the provider for dispensed drugs at rates established in COMAR 10.09.03. The provider shall bill the Program in accordance with COMAR 10.09.03 using the Pharmacy Invoice.</text>
  </paragraph>
  <paragraph num="M.">
    <text>The Program will reimburse the provider for dispensed medical supplies at actual cost or at rates established by COMAR 10.09.12, whichever is less.</text>
  </paragraph>
  <paragraph num="N.">
    <text>Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.</text>
  </paragraph>
  <paragraph num="O.">
    <text>Providers shall bill the Program in the following manner:</text>
    <paragraph num="(1)">
      <text>A physician whose laboratory is not required to be registered pursuant to Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, shall bill the Program for laboratory services in accordance with procedures required under these regulations;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A physician whose laboratory is registered as a medical laboratory pursuant to Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, shall bill the Program for laboratory services in accordance with procedures required under COMAR 10.09.09.</text>
    </paragraph>
  </paragraph>
  <paragraph num="P.">
    <text>Reimbursement.</text>
    <paragraph num="(1)">
      <text>The Program shall reimburse providers for all laboratory and other diagnostic services performed by a physician, or by authorized personnel under that physician's supervision, for that physician's patients.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Reimbursement shall be according to all applicable provisions of COMAR 10.10.06 and fees established according to §D of this regulation.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Maximum reimbursement may not exceed the Medicare laboratory fee established by the Maryland Medicare carrier recognized by the Program.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>The Program shall reimburse providers for mental health services performed by a physician according to the fees established under COMAR 10.21.25 and the requirements of this chapter.</text>
    </paragraph>
  </paragraph>
</regulation>