<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".07" citation="COMAR 10.09.15.07" title_num="10" subtitle_num="09" chapter_num="15" heading="Payment Procedures.">
  <paragraph num="A.">
    <text>The provider shall submit his request for payment on the form designated by the Department including all required documentation.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The Department reserves the right to return to the provider, before payment, all invoices not properly signed and completed.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The provider shall bill the provider's customary fees, but may not bill a fee in excess of that charged the general public for similar services, except for injectable drugs and dispensed medical supplies, in which case the provider shall charge the Program the provider's acquisition cost. 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 Program shall pay for medically necessary covered services at the lower of the provider's amount billed to the Program or the maximum reimbursement rates set forth in COMAR 10.09.02.07D.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Payments on Medicare claims are authorized if:</text>
    <paragraph num="(1)">
      <text>The 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="F.">
    <text>Supplemental payment on Medicare claims are made subject to the limitations of the State budget and 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, 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, but by the Program, according to §E above.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <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;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Laboratory or X-ray services not performed by the provider or under the direct supervision of the provider; or</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Photocopying of medical records when requested by another licensed provider on behalf of the participant.</text>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>The Program will make no direct payment to participants.</text>
  </paragraph>
  <paragraph num="I.">
    <text>The Program shall reimburse providers for all laboratory services according to the fees established under COMAR 10.09.09.07 and for all radiological services under COMAR 10.09.02.07.</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>
</regulation>