<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".06" citation="COMAR 10.09.77.06" title_num="10" subtitle_num="09" chapter_num="77" heading="Payment Procedures.">
  <paragraph num="A.">
    <text>Payment for free-standing urgent care centers is as follows:</text>
    <paragraph num="(1)">
      <text>Urgent care centers are reimbursed a facility fee, which is determined by the Program;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>In addition to the facility fee, the Program shall reimburse for services rendered by the physician, nurse practitioner, or physician assistant during the visit at the free-standing urgent care center; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>If the service is free to individuals not covered by Medicaid:</text>
      <paragraph num="(a)">
        <text>The provider:</text>
        <paragraph num="(i)">
          <text>May charge the Program; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Shall be reimbursed in accordance with the provisions of this regulation; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>The provider's reimbursement is not limited to the provider's customary charge.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Reimbursement by the Program for facility services, which are included in the facility fee, includes:</text>
    <paragraph num="(1)">
      <text>Nursing, technician, and related services;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Use of the center;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances, and any equipment directly related to the treatment of the illness or injury; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Administrative costs.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>The Department shall pay for covered services at 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 for:</text>
      <paragraph num="(a)">
        <text>Professional services in accordance with COMAR 10.09.02.07D; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Laboratory services in accordance with COMAR 10.09.09.07D.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>The provider shall submit a request for payment as set forth in COMAR 10.09.36.04A.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The Program reserves the right to return to the provider, before payment, all invoices that are not properly completed.</text>
  </paragraph>
  <paragraph num="F.">
    <text>The Program shall authorize payment on Medicare claims only 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 the services are medically necessary;</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="G.">
    <text>The Department shall make supplemental payment on Medicare claims subject to the limitations of the State budget and the following provisions:</text>
    <paragraph num="(1)">
      <text>Deductible insurance shall 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 considered medically necessary by the Program, will be paid according to the limitations of Regulation .04 of this chapter.</text>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>The provider may not bill the Program for:</text>
    <paragraph num="(1)">
      <text>Completion of forms and reports;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Broken or missed appointments; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Professional services rendered by mail or telephone.</text>
    </paragraph>
  </paragraph>
  <paragraph num="I.">
    <text>The Program may not make a direct payment to a participant.</text>
  </paragraph>
  <paragraph num="J.">
    <text>Billing time limitations for claims submitted under this chapter are set forth in COMAR 10.09.36.06.</text>
  </paragraph>
</regulation>