Regulation .06 Limitations.
Regulation .06 Limitations.LinkCopy Citation
The Program does not cover the following:
A.
Services not specified in Regulation .04 of this chapter;
B.
Services not medically necessary;
C.
Investigational and experimental drugs and procedures;
D.
Procedures solely for cosmetic purposes;
E.
Services denied by Medicare as not medically justified;
F.
Freestanding clinic services for inpatient participants in State-operated facilities serving individuals with intellectual disabilities;
G.
Freestanding clinic services provided to hospital inpatients;
H.
Freestanding clinic visits when patients are referred to hospital outpatient departments or emergency rooms for services ordinarily provided in freestanding clinics covered by this chapter;
I.
Freestanding clinic visits solely for the purpose of one or more of the following:
(1)
Prescription drugs or collection of laboratory specimens, unless otherwise allowed;
(2)
Certification or recertification of food supplements;
(3)
Performing laboratory tests required only for certification or recertification of food supplement programs;
(4)
Nutritional assessments in the absence of diagnosis of nutritional disorders, unless EPSDT or primary health services are provided at the same time;
(5)
Ascertaining the patient's weight;
(6)
Interpretation of laboratory tests or panels; and
(7)
Measurement of blood pressure;
J.
Office 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 medical record;
K.
More than one visit per day to the same freestanding clinic, unless the additional visit is adequately documented as:
(1)
An emergency situation; or
(2)
A visit to a different specialty;
L.
Central nervous system stimulants and anorectic agents when used for weight control;
M.
Immunizations required solely for travel outside the continental United States;
N.
Vision care services excluded under COMAR 10.09.14 or COMAR 10.09.23;
O.
Separate billing for services which are specifically included as part of another service;
P.
Separate reimbursement to a practitioner for services provided in a freestanding clinic in addition to the freestanding clinic reimbursement;
Q.
Payment for more than one visit to complete an EPSDT screening service;
R.
Visits solely for group or individual health education;
S.
Freestanding clinic visits in addition to an EKG procedure when the EKG procedure is the only purpose for the visit; and
T.
Services for which preauthorization is required under Regulation .09 of this chapter but has not been obtained.