<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".06" citation="COMAR 10.09.17.06" title_num="10" subtitle_num="09" chapter_num="17" heading="Payment Procedures.">
  <paragraph num="A.">
    <text>The provider shall submit the request for payment of services rendered according to procedures established by the Department and in the format designated by the Department.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The provider shall certify on the invoice that the treatment order is on file and was in effect at the time that services were rendered.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The provider shall specify on the invoice the type of treatment provided.</text>
  </paragraph>
  <paragraph num="D.">
    <text>A provider shall bill the Program the provider’s customary charge. 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 the rate provisions of §E 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="E.">
    <text>The services covered in this chapter are reimbursed according to COMAR 10.09.23.01-1.</text>
  </paragraph>
  <paragraph num="F.">
    <text>The Department will pay for covered services, 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 Medicaid; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The Department's fee schedule.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>Supplemental payment on Medicare claims for patients is 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 covered by the Program, according to §F, in this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>Payments on Medicare claims are authorized if:</text>
    <paragraph num="(1)">
      <text>The provider accepts Medicare assignment;</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; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Initial billing is made directly to Medicare according to Medicare guidelines.</text>
    </paragraph>
  </paragraph>
  <paragraph num="I.">
    <text>The provider may not bill the Department for:</text>
    <paragraph num="(1)">
      <text>Services rendered by mail or telephone;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Completion of forms and reports; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Broken or missed appointments.</text>
    </paragraph>
  </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 Department may return to the provider, before payment, all invoices not properly signed, completed, and accompanied by properly completed forms required by the Department.</text>
  </paragraph>
</regulation>