Chapter 36. General Medical Assistance Provider Participation Criteria
Regulation .01 Definitions.LinkCopy Citation
A.
The following terms apply to Medical Assistance providers. Additional defined terms, unique to Medical Assistance provided services, are found in Medical Assistance service-specific chapters.
B.
Terms Defined.
(1)
“Abandoned” means failing to appear for a hearing on the established date without good cause.
(2)
“Administrative law judge” means an individual appointed by the Chief Administrative Law Judge under State Government Article, §9-1604, Annotated Code of Maryland, or designated by the Chief Administrative Law Judge under State Government Article, §9-1607, Annotated Code of Maryland, to:
(a)
Adjudicate contested cases at the Maryland Office of Administrative Hearings; and
(b)
Render a proposed decision for purposes of COMAR 28.02.01.22.
(3)
“Care manager” means a:
(a)
Primary medical provider under the Diabetes Care Program, in accordance with COMAR 10.09.43, or the Maryland Access to Care Program, in accordance with COMAR 10.09.44;
(b)
Primary care provider under the corrective managed care program, in accordance with COMAR 10.09.24.15B and 10.09.25.14B; or
(c)
Hospice provider under the hospice care program, in accordance with COMAR 10.09.35.
(4)
“Claim” means:
(a)
A bill for services;
(b)
A line item of service; or
(c)
All services for one participant within a bill.
(5)
Clean Claim.
(a)
“Clean claim” means a claim that can be processed consistent with applicable regulations without obtaining additional information from the provider of the service or from a third party.
(b)
“Clean claim” includes a claim with errors originating in a State's claims system;
(c)
“Clean claim” does not include a claim:
(i)
From a provider who is under investigation for fraud or abuse; or
(6)
“Current Procedural Terminology (CPT)” means the American Medical Association’s uniform nomenclature for coding medical procedures and services.
(7)
“Customary charge” means the uniform amount that the provider charges in the majority of cases for a specific item or service, excluding token charges for charity patients and substandard charges for welfare and other low-income patients.
(8)
“Department” means the Maryland Department of Health, which is the single state agency designated to administer the Maryland Medical Assistance Program pursuant to Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.
(9)
“Emergency services” means those services which are provided in hospital emergency facilities after the onset of a medical condition manifesting itself by symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected by a prudent layperson, possessing an average knowledge of health and medicine, to result in:
(a)
Placing health in jeopardy;
(b)
Serious impairment to bodily functions;
(c)
Serious dysfunction of any bodily organ or part; or
(d)
Development or continuance of severe pain.
(10)
“Healthcare Common Procedure Coding System (HCPCS)” means the specified code set for procedures and services, according to the Health Insurance Portability and Accountability Act (HIPAA).
(11)
“Managed care" means the care manager's provision of comprehensive primary care and referral services to an enrollee in a managed care program.
(12)
“Managed care program” means:
(a)
Maryland Access to Care Program under COMAR 10.09.44;
(b)
Diabetes Care Program under COMAR 10.09.43;
(c)
Corrective managed care under COMAR 10.09.24.15B or 10.09.25.14B; or
(d)
Hospice care under COMAR 10.09.35.
(13)
“Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.
(14)
“Medical Care Programs" means the unit of the Department responsible for the administration of the Medical Assistance Program.
(15)
“Medically necessary” means that the service or benefit is:
(a)
Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
(b)
Consistent with currently accepted standards of good medical practice;
(c)
The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and
(d)
Not primarily for the convenience of the consumer, family, or provider.
(16)
“Medicare” means the insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.
(17)
Overpayment.
(a)
“Overpayment” means any payment made by the Medicaid Program to a provider for medical care provided to a participant which at the time of payment, or at a subsequent date, is determined to be:
(i)
A duplicate payment;
(ii)
A payment for services for which reimbursement is claimed when all or any part of the claim submitted to the Department is for services that were provided in violation of one or more regulations;
(iii)
Excessive in amount; or
(iv)
The primary obligation of a health insurance carrier or any other person, including the participant, who is legally or contractually obligated to pay for that medical care.
(b)
“Overpayment” does not include an amount recovered as part of a routine cost settlement process.
(18)
“Participant” means a person who is certified as eligible for, and is receiving, Medical Assistance benefits.
(19)
“Primary care” means that medical care which addresses a patient's general health needs including the coordination of the patient's health care, with the responsibility for the prevention of disease, promotion and maintenance of health, treatment of illness, and referral to other specialists for more intensive care when appropriate.
(20)
“Program" means the Medical Assistance Program.
(21)
“Provider” means:
(a)
An individual, association, partnership, corporation, unincorporated group, or any other person authorized, licensed, or certified to provide services for Program participants and who, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of an individual account number;
(b)
An agent, employee, or related party of a person identified in §B(19)(a) of this regulation; or
(c)
An individual or any other person with an ownership interest in a person identified in §B(19)(a) of this regulation.
(22)
“State Department of Assessments and Taxation (SDAT)” means the State Department of Assessments and Taxation as described in COMAR Title 18.
(23)
“Withhold payment” means the Program's decision to not pay or suspend payment to a provider as a sanction for failure to comply with applicable federal or State laws or regulations or because of a credible allegation of fraud.
Regulation .02 License Requirements.LinkCopy Citation
Medical Assistance Program providers shall, to the extent required by law, be licensed, certified, or otherwise legally authorized to practice or deliver services in the state in which the service is provided.
Regulation .03 Conditions for Participation.LinkCopy Citation
A.
To participate in the Program, the provider shall:
(1)
Ensure compliance with all the Medical Assistance provisions listed in the Code of Maryland Regulations (COMAR) designated for their provider type;
(2)
Apply for participation in the Program using the application form designated by the Department;
(3)
Obtain and maintain in good standing the appropriate SDAT identification number in accordance with §I of this regulation;
(4)
Be approved for participation by the Department;
(5)
Allow the Department or its agents to conduct unannounced on-site inspections of any and all provider locations;
(6)
Allow the Department or its agents to require all providers to consent to criminal background checks, including fingerprinting;
(7)
Have a current provider agreement with the Program in effect and fully comply with the terms and conditions stated in the provider agreement;
(8)
Comply with all standards of practice, professional standards and levels of service as set forth in all applicable federal and State laws, statues, rules, and regulations as well as all administrative policies, procedures, transmittals, and guidelines issued by the Department;
(9)
Charge the Program the provider's customary charge to the general public for similar items or services. If the item or service is free to individuals not covered by Medicaid:
(a)
The provider:
(i)
May charge the Program; and
(ii)
Shall be reimbursed in accordance with the Department's rate provisions; and
(b)
The provider's reimbursement is not limited to the provider's customary charge.
(10)
Maintain adequate records for a minimum of 6 years and make them available, upon request, to the Department or its designee;
(11)
Accept payment by the Program as payment in full for covered services rendered and make no additional charge to any person for covered services;
(12)
Provide services without regard to race, color, age, sex, national origin, religion, sexual orientation, gender identity, marital status, or physical or mental disability;
(13)
Verify the participant’s eligibility by:
(a)
Viewing the participant’s Medical Assistance card and another identification card; and
(b)
Calling the Program's Eligibility Verification Interactive Voice Response System (EVS/IVR) or accessing the web-based participant eligibility system;
(14)
Place no restriction on a participant’s right to select health care providers of the participant’s choice, except that a participant in a managed care program shall be required to obtain certain specified Program services from or through the participant's care manager, in accordance with the restrictions imposed by the managed care program;
(15)
Not knowingly employ or contract with a person, partnership, or corporation which has been disqualified from the Program to provide or supply services to Medical Assistance participants unless prior written approval has been received from the Department;
(16)
Notify the Department or its designee of patient activity or circumstance that affects placement, eligibility, or reimbursement, on the form and at the time specified by the Department;
(17)
Maintain the confidentiality of all participant information by not releasing the information without authorization by the participant or as authorized by law;
(18)
Have an individual rendering number for practitioners recognized by the Program;
(19)
Obtain a referral from a participant’s care manager in a manner prescribed by the Department before rendering services, when:
(a)
The participant is enrolled in a managed care program; and
(b)
The service is included under the managed care program's referral requirements.
(20)
Supply a signed service order or prescription that includes the individual rendering number of the ordering or prescribing practitioner, as well as the full name and Medical Assistance number of the participant, when ordering services to be supplied by other providers, such as hospital admission, diagnostic testing, supplies, or pharmacy services;
(21)
Ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed;
(22)
Provide a participant’s medical records at no charge when the records are requested by another physician or licensed provider on behalf of the participant; and
(23)
Comply with the requirements of COMAR 10.01.04.12 regarding the designation of an authorized representative;
(24)
Place no restriction on a participant’s fair hearing appeal rights as a condition of rendering services; and
(25)
Comply with provider audits authorized by State and federal law to ensure compliance with Program requirements.
B.
Enrollment Effective Date.
(1)
Unless a provider is enrolled under the provisions of §B(2) of this regulation, the effective date of a provider’s enrollment is the date the Program completes all screenings required by State and federal law, which may include a site visit, following the Program’s receipt of the provider’s submission of a complete application with all required supporting documents.
(2)
If an out-of-State emergency transportation services or emergency services provider meets provider enrollment requirements, the enrollment effective date is the date the provider renders the emergency services.
C.
A provider may not seek payment from more than one State agency for the same service.
D.
If the Program denies payment or requests repayment on the basis that an otherwise covered service was not medically necessary or preauthorized, the provider may not seek payment for that service from the participant.
E.
If the Program denies payment for covered services for any reason, the provider may not seek payment for the denied service from the participant.
F.
The Program may pay for a covered service rendered by a provider to a participant under any of the following circumstances:
(1)
The provider charges for nonparticipants who receive the same service by:
(a)
Charging the individual in full for services rendered;
(b)
Using a sliding fee scale based on the individual's income;
(c)
Waiving all or part of the fee for a specific individual; or
(d)
Agreeing to accept what a third party pays as payment in full, whether or not the provider bills individuals who lack this coverage;
(2)
The State, using its own funds, pays for services rendered to a targeted group of nonparticipants, and the provider charges nontargeted users of the services;
(3)
The provider bills all individuals with third party coverage, whether or not the provider bills individuals who lack this coverage;
(4)
The service is offered by or through the State agency which administers the program of services authorized under Title V of the Social Security Act; or
(5)
The service is offered to a handicapped child receiving services under the Education for the Handicapped Act (EHA) under an individualized education plan (IEP).
G.
The following types of providers shall comply with the requirements of 42 CFR Part 489, Subpart I, Advance Directives:
(1)
Acute hospitals under COMAR 10.09.92;
(2)
Chronic hospitals under COMAR 10.09.93;
(3)
Special pediatric hospitals under COMAR 10.09.94;
(4)
Special psychiatric hospitals under COMAR 10.09.95;
(5)
Nursing facilities under COMAR 10.09.10 and COMAR 10.09.11;
(6)
Home health agencies under COMAR 10.09.04;
(7)
Personal care case monitors under COMAR 10.09.20;
(8)
Model waiver nursing services providers under COMAR 10.09.27; and
(9)
Hospices under COMAR 10.09.35.
H.
For services that are funded under the Substance Abuse and Mental Health Services Administration and related federal funding sources, specifically for providers that bill the public behavioral health system for specialty mental health services described in COMAR 10.09.59 and community-based substance use disorder services described in COMAR 10.09.80 shall provide data elements per Federal requirements set forth in 42 U.S. Code §300x–9 and 42 USC 300x-35, to the State in the frequency required by the Department.
I.
State Department of Assessments and Taxation (SDAT) Identification Number. A provider shall obtain an SDAT identification number that:
(1)
Identifies their organizational structure as either:
(a)
An individual provider, classified with a prefix of the letter L; or
(b)
A business entity; and
(2)
Is maintained in good standing as described in COMAR 18.04.03.01.
J.
Each provider practice location shall:
(1)
Be individually enrolled with the Program;
(2)
Have an individualized provider agreement as described under §A(6) of this regulation;
(3)
Maintain a unique NPI number as described under §K of this regulation.
K.
National Provider Identification (NPI) Number.
(1)
Unless specifically excepted under §K(2) of this regulation, each provider shall maintain a unique NPI number that:
(a)
Correctly classifies the provider as either:
(i)
An individual provider with a Type 1 NPI number; or
(ii)
An organizational provider with a Type 2 NPI number; and
(b)
For Type 2 organizational providers, is individualized to a specific service or practice location.
(2)
The following enrollment types are exempt from the individualized Type 2 NPI number requirement in §K(1)(b) of this regulation:
(a)
Skilled nursing facility therapy groups with an affiliated nursing facility provider;
(b)
Pharmacies with an affiliated durable medical equipment and disposable medical supplies provider; and
(c)
Hospitals.
L.
Providers may not request or require that a participant waive, revoke, or otherwise forgo Medicaid coverage as a condition for receiving covered services.
Regulation .03-1 Conditions for Participation — Home and Community-Based Settings.LinkCopy Citation
A.
Providers of services under COMAR 10.09.84 shall comply with the provisions of §§D—F of this regulation and 42 CFR 441.301(c)(4).
B.
Effective January 1, 2018, to be enrolled as a provider of services authorized under §§1915(c) or 1915(i) of the Social Security Act, the provider shall comply with the provisions of §§D—F of this regulation and 42 CFR 441.301(c)(4).
C.
Providers of services authorized under §§1915(c) or 1915(i) of the Social Security Act that are enrolled Maryland Medicaid providers before January 1, 2018, shall comply with the provisions of §§D—F of this regulation on or before March 17, 2022.
D.
The setting in which services are provided shall:
(1)
Be integrated in and support full access to the greater community for individuals receiving Medicaid home and community-based services to the same degree of access as individuals not receiving Medicaid home and community-based services;
(2)
Be selected by the individual from among setting options, including nondisability specific settings;
(3)
Be identified and documented in the person-centered service plan and is based on the individual’s needs and preferences;
(4)
Ensure an individual’s rights of:
(a)
Privacy;
(b)
Dignity and respect; and
(c)
Freedom from coercion and restraint;
(5)
Optimize, but not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to:
(a)
Daily activities;
(b)
Physical environment; and
(c)
With whom to interact; and
(6)
Facilitate individual choice regarding services and supports, and who provides them.
E.
In addition to the provisions of §D of this regulation, provider-owned or controlled settings shall meet the following conditions:
(1)
The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual receiving services and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord tenant law of the State, county, city, or other designated entity;
(2)
Each individual has privacy in their sleeping or living unit, as evidenced by the following:
(a)
Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors;
(b)
Individuals sharing units have a choice of roommates; and
(c)
Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement;
(3)
Individuals have the freedom and support to control their own schedules and activities;
(4)
Individuals have access to food at any time;
(5)
Individuals are able to have visitors of their choosing at any time; and
(6)
The setting is physically accessible to the individual.
F.
Any modification of the conditions under §§D and E of this regulation shall be supported by a specific assessed need and justified in the person-centered services plan in accordance with 42 CFR 441.301(c)(2)(xiii).
Regulation .03-2 Conditions for Participation — Data Management Systems and Electronic Visit Verification.LinkCopy Citation
A.
This regulation establishes standards for providers using Data Management systems.
B.
Definitions.
(1)
In this regulation, the following terms have the meanings indicated.
(2)
Terms Defined.
(a)
“Data management system” means a health information technology solution used by the Maryland Department of Health (Department), its agents, providers, and Program participants that stores provider or participant protected health information (PHI) or personally identifiable information (PII) and related business processes.
(b)
“Electronic visit verification (EVV)” means an electronic service entry method used to record service details, including but not limited to service type, provider and participant information, date of service, service delivery location, and beginning and ending times of service that meets the requirements of the 21st Century Cures Act, codified at 42 U.S.C. §1396b(l) and other State or federal guidelines.
(c)
Electronic visit verification (EVV) services means services that are:
(i)
Covered Medicaid services, according to the respective authority, including but not limited to the Medicaid State Plan, a Medicaid waiver program, or regulations; and
(ii)
Required to be electronically recorded in the Department’s EVV system or approved financial management and counseling services contractors’ EVV solutions pursuant to 42 U.S.C. §1396b(l) and other State and federal laws, regulations, or guidance except in circumstances when the services, provided under the agency, traditional, or self-directed delivery model, are provided by a live-in caregiver or worker and exempted by the Department, or otherwise exempted by the Department and the participant elects to forego the electronic process.
(d)
“Financial management and counseling services (FMCS) contractors” means agencies that provide financial management and counseling services to support individuals who choose the self-direction delivery model.
(e)
“Live-in caregiver” means a paid personal caregiver who permanently, or for an extended period of time approved by the Department, resides in the same residence as the Medicaid participant for whom they are providing services and supports.
(f)
“Preauthorized” means approved by the Department or its designee before services are rendered.
(g)
“Worker” means an individual, who may be referred to as a caregiver, who is employed by or contracts with a provider or self-directing participant.
C.
Requirements for Using Data Management Systems. Providers shall:
(1)
Register and credential all system users in the manner specified by the Department with valid and accurate information;
(2)
Properly train all workers registered as system users on proper protocols for conducting system activities, including:
(a)
Accurate entry of information into the system;
(b)
Proper use of hardware and equipment required to use the system;
(c)
EVV, including but not limited to recording and modifying billing entries, participant and provider information, or other records, in accordance with the policies and procedures issued by the Department, unless otherwise exempted by the Department; and
(d)
Protection of protected health information in compliance with State and federal law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA);
(3)
Comply with the laws and regulations concerning the privacy and security of protected health information under State and federal law, including HIPAA; and
(4)
Ensure that any provider-owned systems and devices responsible for sending, retrieving, or storing data from a State-operated data management system comply with all Department, State and federal regulations, policies, and procedures regarding information technology privacy and security.
D.
Requirements for EVV Use.
(1)
Agency providers and workers shall use the EVV method and data management system approved by the Department, unless otherwise exempted by the Department, to:
(a)
Meet the requirements of the 21st Century Cures Act, codified at 42 U.S.C. §1396b(l) and other State or federal guidelines; and
(b)
Submit claims.
(2)
The Department shall reimburse for EVV services if the service is:
(a)
Electronically recorded through the EVV method and data management system approved by the Department in accordance with Department regulations, policies, and procedures;
(b)
Recorded using a manual or alternate electronic timekeeping process and data management system approved by the Department in accordance with Department regulations, policies, and procedures when the live-in caregiver exemption is applicable and elected;
(c)
Preauthorized in the manner designated by the Department for the service type;
(d)
Directly provided to the participant in-person, unless otherwise authorized by the Department; and
(e)
Delivered in accordance with all applicable Department regulations, policies, and procedures for the service type.
(3)
The Program does not cover services, even those exempted from EVV, provided:
(a)
During periods of participant ineligibility;
(b)
During time periods that overlap with the worker’s time period for the same or another participant unless otherwise authorized by the appropriate program authority for the service type; or
(c)
During time periods that overlap with the same or another worker’s time period for the same participant unless otherwise authorized by the appropriate program authority for the service type.
Regulation .04 Payment Procedures.LinkCopy Citation
A.
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.
B.
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.
C.
The Program will make no direct payment to recipients.
D.
All payments are contingent upon a provider’s full compliance with the requirements of its enrollment and applicable conditions of participation.
E.
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.
F.
Unless otherwise excepted, the provider shall be paid the lesser of:
(1)
The provider’s customary charge unless the service is free to individuals not covered by the Program; or
(2)
The Department’s applicable rate.
G.
Unless otherwise excepted, if a service is free to individuals not covered by the Program:
(1)
The provider:
(a)
May charge the Program; and
(b)
Shall be reimbursed in accordance with §F of this regulation; and
(2)
The provider's reimbursement is not limited to the provider's customary charge.
H.
Providers may not bill the Department, the Program, or participants for:
(1)
Completion of forms and reports;
(2)
Broken or missed appointments;
(3)
Covered professional services rendered by:
(a)
Mail;
(b)
Email; or
(c)
Fax; or
(4)
Providing a copy of a participant’s medical record when requested by another licensed provider on behalf of the participant.
I.
Unless otherwise excepted, payments on Medicare claims are authorized, if:
(1)
Services are covered by the Medicare Program;
(2)
The provider accepts Medicare assignments;
(3)
Medicare makes direct payment to the provider;
(4)
Medicare has determined that services were medically justified; and
(5)
Initial billing is made directly to Medicare according to Medicare guidelines.
J.
Unless otherwise provided by regulation, supplemental payments on Medicare claims are made subject to the following provisions:
(1)
Deductible insurance will be paid in full;
(2)
Beginning with August 1, 2010 dates of service and subject to the limitations of the State budget, coinsurance shall be paid:
(a)
In full for the following:
(i)
Mental health services;
(ii)
CPT codes that are priced by report;
(iii)
Claims for anesthesia services;
(iv)
Claims from a federally qualified health center; and
(v)
HCPCS codes beginning with A through W; and
(b)
For all other claims, at the lesser of:
(i)
100 percent of the coinsurance amount; or
(ii)
The balance remaining after the Medicare payment is subtracted from the Medicaid rate; and
(3)
Services not covered by Medicare are payable according to §F of this regulation.
K.
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.
Regulation .05 Cost Reporting.LinkCopy Citation
A.
Providers who are reimbursed on the basis of cost reports shall submit to the Department or its designee, in the form prescribed, financial and statistical data within 3 months after the end of the provider's fiscal year unless the Department grants the provider an extension or the provider discontinues participation in the Program.
B.
If a provider discontinues participation, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination.
C.
An extension shall be granted upon written request by the provider, setting forth the specific reasons for the request, if the Department determines, taking into consideration the totality of the circumstances, that the request is reasonable.
D.
Availability of Records.
(1)
The provider shall keep all records available for inspection or audit by the Department or the Department's designee at any reasonable time during normal business hours.
(2)
Documentation of Costs.
(a)
Upon request by the Department or the Department's designee, the provider shall make documentation of costs available during the course of verification.
(b)
The provider shall have 30 days from the date of the request to provide this documentation.
(c)
Costs for which documentation is not provided within the 30 days shall be considered not allowable.
(3)
Upon written demonstration by the provider of good cause, the Department may grant, in writing, an extension of time to provide the requested documentation.
(4)
Records shall be retained for 6 years after the month in which the cost report to which the materials apply is filed with the Department or the Department's designee.
Regulation .06 Billing Time Limitations.LinkCopy Citation
A.
Definition.
(1)
In this regulation, the following term has the meaning indicated.
(2)
Term Defined. “Received” means:
(a)
The Program taking delivery of a claim after the Program signs a certified mail, return receipt requested parcel from the United States Postal Service; or
(b)
The claim is reported on the provider’s remittance advice.
B.
Unless specified in Regulation .03A(1) of this chapter, the following apply:
(1)
The Department may not reimburse the claims received by the Program for payment more than 12 months after the date of service.
(2)
Medicare Claims. For any claim initially submitted to Medicare and for which services have been:
(a)
Approved, requests for reimbursement shall be submitted and received by the Program within 12 months of the date of service or 120 days from the Medicare remittance date, as shown on the Explanation of Medicare Benefits, whichever is later; and
(b)
Denied, requests for reimbursement shall be submitted and received by the Program within 12 months of the date of service or 120 days from the Medicare remittance date, as shown on the Explanation of Medicare Benefits, whichever is later.
(3)
Fee for Service Claims.
(a)
Fee for service claims shall be submitted and received by the Program within 12 months of:
(i)
The date of service;
(ii)
The date of discharge, if the service was a hospital inpatient service; or
(iii)
The month of service, if the service was provided in a nursing or rehabilitation facility or is a hospice service.
(b)
The Program shall only pay claims for services provided on different dates and submitted on a single claim if the single claim form is received by the Program within 12 months of the earliest date of service.
(c)
The Program shall only pay a claim that was initially rejected, denied, or not acted upon within reasonable promptness after being received by the Program, if the claim is:
(i)
Complete according to Program billing instructions and the 837 HIPAA compliant and companion guidelines;
(ii)
Resubmitted; and
(iii)
Received by the Program within the later of 12 months from the date of service or 60 days from the date last received by the Program or last rejected by the Program.
(4)
A claim for services provided on different dates and submitted on a single form shall be paid only if it is received by the Program within 12 months of the earliest date of service.
(5)
The Program shall only pay a claim that was initially rejected, denied, or not acted upon within reasonable promptness after being received by the Program, if the claim is:
(a)
Complete according to Program billing instructions and the 837 HIPAA compliant and companion guidelines;
(b)
Resubmitted; and
(c)
Received by the Program within the later of:
(i)
12 months from the date of service; or
(ii)
60 days from the date last received by the Program or last rejected by the Program.
(6)
Claims submitted after the time limitations because of a retroactive eligibility determination shall be considered for payment if received by the Program within 12 months of the date on which eligibility was determined.
(7)
Late Charge Billing.
(a)
The Program shall only accept additional or supplemental claims that were not included with a larger primary claim paid by the Program if all of the additional or supplemental claims are:
(i)
Submitted together;
(ii)
Submitted in accordance with the requirements of §B(3) of this regulation; and
(iii)
Received within 60 days of the original paid claim date.
(b)
The Program shall only accept one additional or supplemental claim under §B(7)(a) of this regulation for each:
(i)
Date of service;
(ii)
Date of discharge; or
(iii)
Month of service billed.
(8)
Adjustment Requests. Requests by providers to adjust information in claims already paid, including but not limited to changing the days billed, the amount charged, the units of service, or the rate of the service, shall be submitted to the Program in accordance with §B(3) and (5) of this regulation.
Regulation .07 Recovery and Reimbursement.LinkCopy Citation
A.
If the participant has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for, or to reimburse the participant for, covered services, the provider shall seek payment from that source first. If an insurance carrier rejects the claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Program. The Program shall pay the difference between what was paid by the insurance carrier and the Program's maximum fees. Total payment cannot exceed the Program's maximum fee. The provider shall submit a copy of the insurance carrier's notice or remittance advice with the invoice. If payment is made by both the Program and the insurance or other source for the same service, the provider shall refund to the Department, within 60 days of receipt, the amount paid by the Program or the insurance or other source, whichever is less.
B.
The provider shall reimburse the Department for any overpayment.
C.
The Department may conduct provider audits as authorized by State and federal law to ensure compliance with Program requirements.
D.
For audits commencing on or after July 1, 2004, if the provider fails to reimburse the Department in accordance with §§A and B of this regulation, the provider shall be responsible for reimbursing the Department for the amount of the overpayment and any audit costs incurred by the Department in seeking recovery of the overpayment.
E.
An audit is considered to have commenced upon the initial written notification by the Department or the Department's agent to the provider.
Regulation .08 Cause for Suspension or Removal and Imposition of Sanctions.LinkCopy Citation
A.
If the Department determines that a provider, any agent or employee of the provider, or any person with an ownership interest in the provider or related party of the provider has failed to comply with applicable federal or State laws or regulations, the Department may initiate one or more of the following actions against the responsible party:
(1)
Suspension from the Program;
(2)
Withholding of payment by the Program;
(3)
Recovery of an overpayment;
(4)
Removal from the Program; and
(5)
Disqualification from future participation in the Program, either as a provider or as a person providing services for which Program payment will be claimed.
B.
If the Secretary of Health and Human Services suspends or removes a provider from participation in Medicare, the Department shall take similar action.
C.
The Department may report to the federal Secretary of Health and Human services any providers removed from participation with the Program for failure to comply with applicable federal or State laws and regulations in accordance with 42 CFR §455.416.
D.
The Department shall give the provider reasonable notice of its intention to impose sanctions. In the written notice, the Department shall establish the effective date and the reasons for the proposed action, and advise the provider of the right to appeal.
E.
A provider who voluntarily withdraws from the Program, or is removed or suspended from the Program according to this regulation, shall notify participants, before rendering additional services, that the provider no longer honors Medical Assistance cards.
Regulation .09 Filing Appeal.LinkCopy Citation
A.
Source of Appeals.
(1)
A provider may file an appeal from a proposed Program action to:
(a)
Suspend the provider from the Program;
(b)
Withhold payment by the Program;
(c)
Recover an overpayment;
(d)
Remove the provider from the Program; or
(e)
Disqualify the provider from future participation in the Program, either as a provider or as a person providing services for which Program payment will be claimed.
(2)
A provider shall submit an appeal according to:
(a)
COMAR 10.01.03;
(b)
State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland;
(c)
Health-General Article, §§2-201—2-207, Annotated Code of Maryland; and
(d)
COMAR 28.02.01.
(3)
A provider may not file an appeal from a Program action to terminate the provider when that action is the result of either:
(a)
Termination of the provider or an owner by the federal government or another state Medicaid agency pursuant to 42 CFR §445.416; or
(b)
Suspension or termination of the provider’s license or certificate by their respective licensing or certification authority.
B.
Request for a Hearing.
(1)
An appeal of a proposed Program action shall be filed in writing with the Program within 30 days of the date of the notice of the proposed Program action. The Program shall make reasonable accommodation if a provider cannot submit a written request because of a disability.
(2)
The Program shall immediately forward a written appeal request to the Office of Administrative Hearings.
(3)
The Office of Administrative Hearings shall:
(a)
Promptly acknowledge any appeal; and
(b)
Notify the provider and the Program in writing of the date, time, and place of the hearing.
C.
Effective Date. The proposed Program action shall be effective on:
(1)
The date of the proposed Program action notice if the Program:
(a)
Determines that the provider poses an imminent threat to public health, safety, or welfare that requires emergency action; and
(b)
Notifies the provider of this determination in the proposed Program action notice;
(2)
The date specified in the proposed Program action notice if the provider:
(a)
Does not request a hearing within 30 days of the date of the notice of the proposed Program action; or
(b)
Withdraws in writing or abandons a request for a hearing before the effective date of the proposed Program action;
(3)
The first payment date following the date of the Program action notice if the Program action involves withholding payment to the provider because the Program discovered an overpayment to the provider;
(4)
The date the administrative law judge renders a decision in favor of the Program if the provider:
(a)
Fails to timely file exceptions to the administrative law judge's decision with the Secretary pursuant to §D of this regulation; or
(b)
Withdraws in writing or abandons a request for an exceptions hearing before the date of the exceptions hearing; or
(5)
The date the Secretary renders a decision in favor of the Program pursuant to COMAR 10.01.03 if any party files exceptions with the Secretary in accordance with §E(1) of this regulation.
D.
A Program determination to suspend payments due to a credible allegation of fraud shall be effective immediately unless the Department determines, consistent with 42 CFR §455.23, that a good cause exception to immediate suspension exists.
E.
Exceptions and Outcomes.
(1)
A party may seek additional administrative review of the administrative law judge's decision by filing in writing exceptions with the Secretary within 30 days of the date of the administrative law judge's decision pursuant to COMAR 10.01.03.
(2)
If the Secretary's decision is favorable to the Program, the Program may:
(a)
Immediately implement the proposed Program action; and
(b)
Institute recovery procedures against the provider to recoup the cost of any payments made to the provider to the extent the payments were made solely because the provider was permitted to continue to submit claims to the Department because of §C(5) of this regulation.
(3)
If the proposed Program action was effective on the date of the notice as provided for in §B(1) of this regulation, the Program shall authorize corrected payments or relief retroactive to the date of the notice if:
(a)
The Secretary's decision is favorable to the provider; or
(b)
The Program grants the provider the relief the provider requests before the Secretary's decision.
F.
Further Appeals. The provider may seek additional administrative review of the Secretary's decision as provided in Health-General Article, §§2-206 and 2-207, Annotated Code of Maryland, and subsequent judicial review as provided in State Government Article, §10-215, Annotated Code of Maryland.
Regulation .10 Interpretive Regulation.LinkCopy Citation
Except when the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program participants without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations.
Regulation .11 Provider Rights.LinkCopy Citation
Providers participating in the Program shall have the right to:
A.
Be treated professionally with courtesy, dignity, and respect regardless of the individual's:
(1)
Race;
(2)
Color;
(3)
Religion;
(4)
Gender;
(5)
Sexual orientation;
(6)
National origin;
(7)
Political affiliation;
(8)
Disability;
(9)
Marital status;
(10)
Age; or
(11)
Union affiliation;
B.
File a complaint with the appropriate State agency when the provider believes that the provider has been discriminated against because of:
(1)
Race;
(2)
Color;
(3)
Religion;
(4)
Gender;
(5)
Sexual orientation;
(6)
National origin;
(7)
Political affiliation;
(8)
Disability;
(9)
Marital status;
(10)
Age; or
(11)
Union affiliation;
C.
Have the information in the provider's Program file kept confidential except as otherwise stated by State or federal law;
D.
Be reimbursed for covered services provided to Program participants; and
E.
Participate in an impartial grievance and appeals process as outlined in COMAR 10.09.36.09.
Chapter annotations
Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
History: Effective date:
History: Regulations .01—.10 adopted as an emergency provision effective July 1, 1990 (17:15 Md. R. 1851); adopted permanently effective October 1, 1990 (17:18 Md. R. 2201)
History: Regulations .01A and .03A amended, and .03D adopted as an emergency provision effective February 27, 1992 (19:6 Md. R. 669); adopted permanently effective June 22, 1992 (19:11 Md. R. 1015)
History: Regulations .01A, .06A, B amended, and .06C—E adopted as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004)
History: Regulations .01A and .06 amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004)
History: Regulation .01B amended effective May 9, 2005 (32:9 Md. R. 849); August 27, 2007 (34:17 Md. R. 1507); January 24, 2011 (38:2 Md. R. 84); July 4, 2016 (43:13 Md. R. 712); June 14, 2021 (48:12 Md. R. 473); September 18, 2023 (50:18 Md. R. 794); August 5, 2024 (51:15 Md. R. 707); July 21, 2025 (52:14 Md. R. 713)
History: Regulation .02 amended effective September 18, 2023 (50:18 Md. R. 794)
History: Regulation .03 amended as an emergency provision effective September 16, 1992 (19:20 Md. R. 1812); amended permanently effective January 1, 1993 (19:25 Md. R. 2205)
History: Regulation .03 amended effective January 1, 2018 (44:26 Md. R. 1215); September 18, 2023 (50:18 Md. R. 794); July 21, 2025 (52:14 Md. R. 713)
History: Regulation .03A amended effective June 14, 2010 (37:12 Md. R. 800); December 10, 2012 (39:24 Md. R. 1577); November 11, 2013 (40:22 Md. R. 1877); February 16, 2015 (42:3 Md. R. 316); March 28, 2016 (43:6 Md. R. 407); July 4, 2016 (43:13 Md. R. 712)
History: Regulation .03-1 adopted effective February 26, 2018 (45:4 Md. R. 206)
History: Regulation .03-2 adopted effective April 4, 2022 (49:7 Md. R. 466); amended effective August 5, 2024 (51:14 Md. R. 707)
History: Regulation .04 amended effective August 5, 2024 (51:15 Md. R 707)
History: Regulation .04H amended effective July 21, 2025 (52:14 Md. R. 713)
History: Regulation .05D adopted effective August 12, 1996 (23:16 Md. R. 1175)
History: Regulation .06 amended effective June 1, 1993 (20:10 Md. R. 852); January 12, 2009 (36:1 Md. R. 21); June 27, 2011 (38:13 Md. R. 755)
History: Regulation .07 amended effective September 18, 2023 (50:18 Md. R. 794)
History: Regulation .07C, D adopted effective May 9, 2005 (32:9 Md. R. 849)
History: Regulation .08A, D amended effective June 14, 2021 (48:12 Md. R. 473)
History: Regulation .08C adopted effective July 21, 2025 (52:14 Md. R. 713)
History: Regulation .09 repealed and new Regulation .09 adopted effective January 24, 2011 (38:2 Md. R. 84)
History: Regulation .09 amended effective June 14, 2021 (48:12 Md. R. 473)
History: Regulation .09A amended effective September 18, 2023 (50:18 Md. R. 794)
History: Regulation .10 amended effective September 18, 2023 (50:18 Md. R. 794)
History: Regulation .11 adopted effective June 27, 2011 (38:13 Md. R. 755)
History: Regulation .11D amended effective September 18, 2023 (50:18 Md. R. 794)