<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".12" citation="COMAR 10.14.02.12" title_num="10" subtitle_num="14" chapter_num="02" heading="Medical Laboratory Services.">
  <paragraph num="A.">
    <text>To be considered a participating medical laboratory in the Program, the provider shall:</text>
    <paragraph num="(1)">
      <text>Be in compliance with the applicable license requirements for a medical laboratory providing services for Maryland residents including, but not limited to:</text>
      <paragraph num="(a)">
        <text>Requirements for Medicare certification;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Compliance with the requirements pursuant to COMAR 10.10.03.01 if operating in Maryland; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Requirements for the Federal Clinical Laboratory Improvement Act of 1988, 42 U.S.C. §263a;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Agree to accept as payment in full for the reimbursed service, the amount paid by the Program as specified in §E of this regulation plus, if applicable, the amount paid by the eligible patient's health insurer and the patient contribution amount;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Agree not to bill an eligible patient for an additional charge for the medical laboratory services provided;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Abide by the provisions set forth in this regulation by signing and sending to the Department the designated Departmental form;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Place no restriction on the eligible patient's right to select a provider; and</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Maintain records adequate to substantiate the ordering, performance, and reporting of laboratory procedures performed or referred for a minimum of 6 years, and, upon request, allow the Department access to the records.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>A reimbursed service includes but is not limited to the following:</text>
    <paragraph num="(1)">
      <text>Preparation, analysis, and interpretation of a cervical biopsy, endometrial biopsy, vaginal biopsy, and breast biopsy; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A laboratory procedure or service related to the diagnosis and treatment of breast cancer, cervical cancer, or a precancerous cervical lesion.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>A non-reimbursed service includes but is not limited to the following:</text>
    <paragraph num="(1)">
      <text>A laboratory service not directly related to the diagnosis and treatment of breast cancer, cervical cancer, or a precancerous cervical lesion;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A service for which there does not exist an order signed by a participating health care provider;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A procedure for which the laboratory has not been certified by Medicare;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>A service not provided according to the laws and regulations of the jurisdiction in which the service is rendered;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>A procedure that is investigational or experimental in nature; and</text>
    </paragraph>
    <paragraph num="(6)">
      <text>A service included and paid for by the Program as part of the total charge submitted by an inpatient facility or hospital outpatient department.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Reimbursement Procedures. The participating medical laboratory is responsible for:</text>
    <paragraph num="(1)">
      <text>Submitting a bill for the reimbursed service provided on the form designated by the Department within 12 months of the date of service as follows:</text>
      <paragraph num="(a)">
        <text>If an eligible patient is uninsured or has insurance that does not provide coverage for the reimbursed service, the participating medical laboratory shall send the bill to the Department; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>If an eligible patient is covered by Medicare or other insurance, the participating medical laboratory shall bill:</text>
        <paragraph num="(i)">
          <text>Medicare or the other insurance for the service; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The Department for the outstanding deductible and patient contribution amount; and</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Keeping in the records, for each invoice, a copy of the signed orders from a participating health care provider requesting the service.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Payment Procedures.</text>
    <paragraph num="(1)">
      <text>The Department shall pay the participating medical laboratory for a reimbursed service:</text>
      <paragraph num="(a)">
        <text>Pursuant to COMAR 10.09.09.07E for an eligible patient who is uninsured or has insurance that does not provide coverage for the reimbursed service; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Pursuant to COMAR 10.09.09.07F and G(1) and 100 percent of co-insurance for an approved procedure for an eligible patient who is covered by Medicare.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The Department may not reimburse for:</text>
      <paragraph num="(a)">
        <text>Completion of a form or report;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A broken or missed appointment; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A service which is normally provided at no charge.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>The Program shall reimburse for claims pursuant to this regulation as set forth in Regulation .21 of this chapter.</text>
  </paragraph>
</regulation>