<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".02" citation="COMAR 10.21.25.02" title_num="10" subtitle_num="21" chapter_num="25" heading="General Reimbursement.">
  <paragraph num="A.">
    <text>The Department shall reimburse the lower of the amount billed or the fee established under this chapter, after the application of an individual's copayment, based on the ability-to-pay determination according to Regulation .03 of this chapter.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The Department may reimburse for non-Medicaid-reimbursable mental health services to the extent that State resources permit.</text>
  </paragraph>
  <paragraph num="C.">
    <text>According to the provisions of this chapter, the Department shall reimburse a mental health services provider:</text>
    <paragraph num="(1)">
      <text>That is:</text>
      <paragraph num="(a)">
        <text>A community-based mental health program that is approved by the Department; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>An appropriately credentialed individual practitioner who contracts with the Department's Medical Assistance Program;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>For specific services that are delivered to:</text>
      <paragraph num="(a)">
        <text>Medicaid recipients; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Individuals for whom, because of the severity of their mental illness and their financial need, the cost of mental health services is subsidized, in whole or in part, by State general funds for services not reimbursed under a grant or a contract.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>This chapter does not establish fees for services that are provided by:</text>
    <paragraph num="(1)">
      <text>A federally qualified health center;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>An inpatient facility regulated by the Health Services Cost Review Commission, to an inpatient or resident of the facility; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A home health agency licensed under COMAR 10.09.04.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>The mental health service provider shall bill services using:</text>
    <paragraph num="(1)">
      <text>The procedural terminology codes contained in the most current Physician's Current Procedural Terminology (CPT) manual published by the American Medical Association and incorporated by reference in COMAR 10.09.09.07D; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>If there is no current CPT code for the service, a customized code published by the Administration.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>The mental health service provider, by submitting a claim for reimbursement for service, certifies that the service is medically necessary, has been delivered and meets the description and intent of the CPT code which is contained on its claim for reimbursement.</text>
  </paragraph>
  <paragraph num="G.">
    <text>Medicare Recipients.</text>
    <paragraph num="(1)">
      <text>If a provider renders services to individuals who are Medicare recipients, the provider shall comply with all federal Medicare requirements.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>If a provider does not comply with all Medicare requirements, the provider may not seek reimbursement by the PMHS.</text>
    </paragraph>
  </paragraph>
</regulation>