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<regulation prefix="Regulation" num=".09" citation="COMAR 10.14.02.09" title_num="10" subtitle_num="14" chapter_num="02" heading="Hospital Services.">
  <paragraph num="A.">
    <text>To be considered a participating hospital in the Program, the provider shall:</text>
    <paragraph num="(1)">
      <text>Be licensed as a hospital in Maryland or a jurisdiction bordering Maryland;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Agree to abide by the provisions set forth in this regulation by signing and sending to the Department the designated Departmental form;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Agree to accept, as payment in full, the amount paid by the Program pursuant to §E of this regulation;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Agree not to bill an eligible patient for an additional charge for the reimbursed hospital services provided; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Maintain adequate records for a minimum of 5 years and, upon request, allow the Department access to the records.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>The participating hospital shall receive reimbursement for the following services:</text>
    <paragraph num="(1)">
      <text>Medically necessary inpatient hospital service for the number of days, per admission, including preoperative days certified by the utilization control agent, which is:</text>
      <paragraph num="(a)">
        <text>Necessary for the provision of diagnostic, curative, palliative, or rehabilitative treatment for breast cancer or cervical cancer; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Described in the eligible patient's medical record in sufficient detail to support the invoices submitted for services; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Medically necessary outpatient hospital service which is:</text>
      <paragraph num="(a)">
        <text>Necessary for the provision of diagnostic, curative, palliative, or rehabilitative treatment for breast cancer or cervical cancer; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Described in the eligible patient's medical record in sufficient detail to support the invoices submitted for services.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Limitations. The limitations on coverage of some hospital inpatient and outpatient services contained in COMAR 10.09.92.05 apply to this Program.</text>
  </paragraph>
  <paragraph num="D.">
    <text>Preauthorization Requirements.</text>
    <paragraph num="(1)">
      <text>The following surgical procedures require preauthorization when performed on a hospital inpatient basis unless the patient is already a hospital inpatient for another condition, or an unrelated procedure is being done simultaneously which itself requires surgical hospitalization. If an emergency necessitates performing any of the listed procedures on an inpatient basis, the provider shall request and obtain post-authorization before billing. The procedures are:</text>
      <paragraph num="(a)">
        <text>Biopsy;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Breast biopsy if a two-stage procedure is planned for a possible malignancy;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Colposcopy;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Cryotherapy alone;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Cryotherapy with biopsy or dilation and curettage, or both;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Dilation and curettage;</text>
      </paragraph>
      <paragraph num="(g)">
        <text>Excision of benign lesion; and</text>
      </paragraph>
      <paragraph num="(h)">
        <text>Hysteroscopy.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Authorization is required by the Program for all preoperative inpatient days.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>The participating hospital is responsible for:</text>
    <paragraph num="(1)">
      <text>Submitting a bill for the reimbursed services provided on the designated Departmental form as follows:</text>
      <paragraph num="(a)">
        <text>If an eligible patient is uninsured, or is insured but the insurance does not provide coverage for the reimbursed service, the participating hospital shall send the Department the bill for the service, with a denial from the patient’s insurance carrier, within 12 months of the date of discharge or outpatient service; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>If an eligible patient is covered by Medicare or other insurance, the participating hospital shall bill:</text>
        <paragraph num="(i)">
          <text>Medicare or the other insurance for the procedure or service; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The Department for the outstanding deductible and patient contribution amount;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Documenting the sum collected from the eligible patient's insurer as a patient collection; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Submitting properly completed attachments with the bill as requested by the Department.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>Reimbursement Principles.</text>
    <paragraph num="(1)">
      <text>The Program shall reimburse for a room and board charge for the day of admission, and may not reimburse for a room and board charge for the day of discharge from the participating hospital.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The participating hospital may not collect a total payment, including the eligible patient's insurance and the Department's payment, which exceeds the provider's rate established by the Department or its designee.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A participating hospital may not bill the Program a charge exceeding that charged the general public for a similar service.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>The Department may not reimburse the participating hospital for:</text>
      <paragraph num="(a)">
        <text>Completion of a form or report;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A broken or missed appointment;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A professional service rendered by mail or telephone; or</text>
      </paragraph>
      <paragraph num="(d)">
        <text>A service which is provided at no charge to the general public.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(5)">
      <text>The Department may not make direct payment to an eligible patient.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>Reimbursement Rates.</text>
    <paragraph num="(1)">
      <text>A participating hospital located in Maryland shall be reimbursed by the Department:</text>
      <paragraph num="(a)">
        <text>Pursuant to COMAR 10.09.92.07A(2)—(4) and B for an eligible patient who is uninsured or who has insurance that does not provide coverage for the reimbursed service;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Pursuant to COMAR 10.09.92.07A(8) and (9) for an eligible patient who is covered by Medicare; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>For an eligible patient who has insurance other than Medicare that provides coverage for the reimbursed service, the outstanding deductible and patient contribution amount required by the insurer.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>A participating hospital located in a state bordering Maryland shall be reimbursed by the Department:</text>
      <paragraph num="(a)">
        <text>Pursuant to COMAR 10.09.92.07B for an eligible patient who is uninsured or who has insurance that does not provide coverage for the reimbursed service;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Pursuant to COMAR 10.09.92.07A(8) and (9) for an eligible patient who is covered by Medicare; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>For an eligible patient who has insurance other than Medicare that provides coverage for the reimbursed services, the outstanding deductible and patient contribution amount required by the insurer.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>A participating hospital located in the District of Columbia shall be reimbursed by the Department:</text>
      <paragraph num="(a)">
        <text>Pursuant to COMAR 10.09.92.08A and B for an eligible patient who is uninsured or who has insurance that does not provide coverage for the reimbursed service;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Pursuant to COMAR 10.09.92.07A(8) and (9) for an eligible patient who is covered by Medicare; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>For an eligible patient who has insurance other than Medicare that provides coverage for the reimbursed services, the outstanding deductible, and patient contribution required by the insurer.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>The Program shall reimburse for claims submitted pursuant to this regulation as set forth in Regulation .21 of this chapter.</text>
  </paragraph>
</regulation>