<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".06" citation="COMAR 10.09.80.06" title_num="10" subtitle_num="09" chapter_num="80" heading="Limitations.">
  <paragraph num="A.">
    <text>The Program under this chapter does not cover the following:</text>
    <paragraph num="(1)">
      <text>Community-based substance use disorder services not specified in Regulation .05 of this chapter;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Community-based substance use disorder services not approved by a licensed physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Services not identified by the Department as medically necessary or listed in Regulation .05 of this chapter;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Investigational and experimental drugs and procedures;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Substance use disorder visits solely for the purpose of:</text>
      <paragraph num="(a)">
        <text>Prescribing medication;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Administering medication;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Drug or supply pick-up;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Collecting laboratory specimens;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Interpreting laboratory tests or panels; or</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Administering injections, unless the following are documented in the participant’s medical record:</text>
        <paragraph num="(i)">
          <text>Medical necessity; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The participant’s inability to take appropriate oral medications;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>Services that are provided in a hospital inpatient or outpatient setting or in an intermediate care facility for behavioral health;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Services beyond the provider’s scope of practice;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Services that are separately billed but included as part of another service;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Buprenorphine induction and buprenorphine maintenance therapy services that are:</text>
      <paragraph num="(a)">
        <text>Delivered by a participant’s primary care provider which are the responsibility of the Managed Care Organization as specified in COMAR 10.67.08; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Delivered without a primary diagnosis of substance use disorder;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(10)">
      <text>Presumptive and definitive drug testing when billed by:</text>
      <paragraph num="(a)">
        <text>An opioid treatment program;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>An intensive outpatient program; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A partial hospitalization program provider; (</text>
      </paragraph>
    </paragraph>
    <paragraph num="(11)">
      <text>Peer recovery support services that are not provided either in-person or via telehealth; and</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Services not authorized consistent with this chapter.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Providers may not be reimbursed by the Program for:</text>
    <paragraph num="(1)">
      <text>More than one comprehensive substance use disorder assessment for a participant per provider per 12-month period unless there is a break in treatment over 30 calendar days;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>More than one Level 1 group counseling session per day per participant;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>More than six Level 1 individual counseling units as measured in 15 minute increments per day per participant;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>More than four sessions of Level 2.1 Intensive Outpatient treatment per week;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Level 1 group or individual counseling during the same week as a Level 2.1 Intensive Outpatient treatment or Level 2.5 Partial Hospitalization service unless the participant has been discharged from or admitted to a new level of care;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Overlapping episodes of Level 2.1 Intensive Outpatient treatment and Level 2.5 Partial Hospitalization;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Level 1 group or individual counseling during the same week as Level 1 group or individual counseling offered by another provider;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Psychiatric day treatment service as described in COMAR [10.09.02.01] 10.63.03.08 or an intensive outpatient mental health service on the same day as a Level 2.1 Intensive Outpatient program or Level 2.5 Partial Hospitalization program</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Buprenorphine maintenance therapy delivered by an opioid treatment program or a BHA licensed substance use disorder treatment provider during the same week as Methadone Maintenance Therapy;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Ambulatory withdrawal management during the same week as an opioid maintenance therapy, medication assisted treatment induction, or buprenorphine maintenance service;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Medication management billed by an opioid treatment program or a BHA licensed substance use disorder treatment provider during the same days as medication assisted treatment induction;</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Community-based substance use disorder services on the same day that a participant received similar services as a hospital inpatient or outpatient;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Services delivered by federally qualified health centers other than those billed using T-codes that may include the following delivered by two separate appropriately licensed providers:</text>
      <paragraph num="(a)">
        <text>One T-code for mental health services per day with associated mental health procedure code; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>One T-code for substance use disorder services with associated H-code per day;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(14)">
      <text>Services rendered but not appropriately documented to the level of service;</text>
    </paragraph>
    <paragraph num="(15)">
      <text>Services rendered by mail;</text>
    </paragraph>
    <paragraph num="(16)">
      <text>Completion of forms or reports;</text>
    </paragraph>
    <paragraph num="(17)">
      <text>Broken or missed appointments;</text>
    </paragraph>
    <paragraph num="(18)">
      <text>Travel to and from site of service; and</text>
    </paragraph>
    <paragraph num="(19)">
      <text>Transportation costs.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>In order to bill for an individual in Level 2.1 Intensive Outpatient treatment, the per diem session shall include a minimum of 2 hours. A maximum of 4 per diems may be billed per week.</text>
  </paragraph>
  <paragraph num="D.">
    <text>In order to bill for an individual in Level 2.5 Partial Hospitalization, the per diem rate for a half day session shall include a minimum of 2 hours.</text>
  </paragraph>
  <paragraph num="E.">
    <text>In order to bill for an individual in Level 2.5 Partial Hospitalization, the per diem rate for a full day session shall include a minimum of 6 hours.</text>
  </paragraph>
  <paragraph num="F.">
    <text>The Department shall pay participating opioid treatment programs, per participant, per week provided the participant received ongoing opioid treatment medications and at least one face-to-face documented treatment service in the month for which the Program is billed.</text>
  </paragraph>
  <paragraph num="G.">
    <text>In order for an opioid treatment program to bill for medication assisted treatment induction, the provider shall bill this service only in the first week of treatment per participant or in the first week of treatment after a break from treatment of at least 6 months.</text>
  </paragraph>
  <paragraph num="H.">
    <text>In order for an opioid treatment program to bill for buprenorphine maintenance therapy, the provider shall bill this service per participant per week.</text>
  </paragraph>
  <paragraph num="I.">
    <text>In order to bill for ambulatory withdrawal management, providers may bill up to 5 per diems during the detoxification episode if determined medically necessary by the Department.</text>
  </paragraph>
  <paragraph num="J.">
    <text>Peer recovery support services may not be used to supplant the minimum billing requirements for:</text>
    <paragraph num="(1)">
      <text>Level 2.1 Intensive Outpatient treatment as described in §C of this regulation;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Level 2.5 Partial Hospitalization half day session as described in §D of this regulation;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Level 2.5 Partial Hospitalization full day session as described in §E of this regulation; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Opioid treatment program services as described in §F of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="K.">
    <text>All drug screening lab claims submitted to the ASO by providers other than opioid treatment programs shall list the applicable substance use disorder diagnosis.</text>
  </paragraph>
</regulation>