<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".04" citation="COMAR 10.09.36.04" title_num="10" subtitle_num="09" chapter_num="36" 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 Department reserves the right to return to the provider, before payment, all claims not properly signed, completed, and accompanied by properly completed forms required by the Department.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The Program will make no direct payment to recipients.</text>
  </paragraph>
  <paragraph num="D.">
    <text>All payments are contingent upon a provider’s full compliance with the requirements of its enrollment and applicable conditions of participation.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Unless the service is free to the general public, the provider shall charge the Program its customary charge to the general public for similar services.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Unless otherwise excepted, the provider shall be paid the lesser of:</text>
    <paragraph num="(1)">
      <text>The provider’s customary charge unless the service is free to individuals not covered by the Program; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The Department’s applicable rate.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>Unless otherwise excepted, if a service is free to individuals not covered by the Program:</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 §F 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="H.">
    <text>Providers may not bill the Department, the Program, or participants 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>Covered professional services rendered by:</text>
      <paragraph num="(a)">
        <text>Mail;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Email; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Fax; or</text>
      </paragraph>
    </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="I.">
    <text>Unless otherwise excepted, payments on Medicare claims are authorized, if:</text>
    <paragraph num="(1)">
      <text>Services are covered by the Medicare Program;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The provider accepts Medicare assignments;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Medicare makes direct payment to the provider;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Medicare has determined that services were medically justified; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Initial billing is made directly to Medicare according to Medicare guidelines.</text>
    </paragraph>
  </paragraph>
  <paragraph num="J.">
    <text>Unless otherwise provided by regulation, 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 §F of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="K.">
    <text>An individual or entity who is employed by or under contract to any group provider, clinic, or hospital may not bill for any service for which reimbursement is sought by the group provider, clinic, or hospital.</text>
  </paragraph>
</regulation>