Maryland Administrative Code

.08 Payment Procedures. A. Requests for Payment. (1) All requests for payment of services rendered shall be submitted in accordance with COMAR 10.09.36. (2) Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36. B. Payment to a pro…

.09 Recovery and Reimbursement. Recovery and reimbursement shall be in accordance with COMAR 10.09.36. Cross References 10.09.46.13

.10 Cause for Suspension or Removal and Imposition of Sanctions. Cause for suspension or removal and imposition of sanctions shall be in accordance with COMAR 10.09.36.

.11 Appeal Procedures. Appeal procedures shall be in accordance with COMAR 10.09.36.

.12 Interpretive Regulation. State regulations shall be interpreted in accordance with COMAR 10.09.36.

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “All-inclusive cost-per-visit rate” means the rate that is established for Federally Qualified Health Centers (FQHCs) which includes all services that are rendered to a par…

.02 License Requirements. A. The provider shall meet all license requirements as set forth in COMAR 10.09.36.02. B. A physician or osteopath providing services in a freestanding clinic shall be licensed and legally authorized to practice medicine in the state in which the service…

.03 Conditions for Participation. A. General requirements for participation in the Program are that a provider shall: (1) Meet all the conditions for participation as set forth in COMAR 10.09.36; and (2) If delivering services via telehealth, comply with COMAR 10.09.49 and any su…

.04 Covered Services. A. The Program covers the services listed in §§B—E of this regulation according to the conditions and requirements indicated. B. Medically Necessary Services. The program covers medically necessary services as described in §§C, D, and E of this regulation an…

.05 Federally Qualified Health Center Services. A. To participate as a federally qualified health center, the provider shall meet the requirements of Regulations .03 and .04B of this chapter and shall: (1) Meet the conditions for coverage in accordance with 42 CFR §491, Subpart A…

.06 Limitations. The Program does not cover the following: A. Services not specified in Regulation .04 of this chapter; B. Services not medically necessary; C. Investigational and experimental drugs and procedures; D. Procedures solely for cosmetic purposes; E. Services denied by…

.07 Freestanding Clinic Reimbursement Methodology. A. Reimbursement for Family Planning Clinics. The Department shall pay the family planning clinic the lesser of the provider’s customary charge or the provider’s acquisition cost, but no more than the maximum reimbursement allowe…

.08 Reimbursement Methodology for FQHC Services. A. Federally qualified health centers shall be reimbursed for covered services once the provider is in compliance with all federal and State requirements. B. The only well-child visits that are eligible for Program reimbursement ar…

.09 Preauthorization Requirements. A. The following procedures or services require preauthorization: (1) Vision care according to COMAR 10.09.14.06 and COMAR 10.09.23; (2) Mental health services which shall comply with the requirements of COMAR 10.09.59; (3) Substance use disorde…

.10 Payment Procedures. A. The provider shall submit a completed request for payment in the format designated by the Department with any required documentation. B. The Program reserves the right to return to the provider, before payment, all invoices not properly completed with a…

.11 Recovery and Reimbursement. Recovery and reimbursement are as set forth in COMAR 10.09.36.07.

.12 Cause for Suspension or Removal and Imposition of Sanctions. Cause for suspension or removal and imposition of sanctions are as set forth in COMAR 10.09.36.08.

.13 Appeal Procedures. Providers filing appeals from administrative decisions made in connection with this chapter shall do so according to COMAR 10.09.36.09.

.14 Interpretive Regulation. State regulations shall be interpreted in conformity with COMAR 10.09.36.10.

.01 Definitions. A. In addition to the definitions contained in §B of this regulation, definitions set forth in COMAR 10.09.36.01 are applicable to this chapter. B. Terms Defined. (1) “Authorized practitioner” means a physician, osteopath, dentist, podiatrist, nurse midwife, nurs…

.02 License Requirements. A. The provider shall meet all license requirements as set forth in COMAR 10.09.36.02. B. Medical laboratories are required to ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services perform…

.03 Conditions for Participation. A. General requirements for participation in the Program are that a provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03, except that a signature on the services order specified in COMAR 10.09.36.03A(19) is not r…

.04 Covered Services. The Program covers the following services: A. Medically necessary laboratory services, when the services are: (1) Rendered to participants in a physician's office, hospital, freestanding clinic, or medical laboratory; (2) Provided according to the laws and r…

.05 Limitations. The following are not covered: A. Services for which the medical laboratory provider cannot supply a properly completed order or standing order identifying the individual practitioner who ordered the laboratory services; B. Services not adequately documented in t…

.06 Preauthorization Requirements. A. Preauthorization is required for any service identified as needing preauthorization in the current laboratory fee schedule, in accordance with Regulation .07D of this chapter. B. The provider shall submit the request for preauthorization acco…

.07 Payment Procedures. A. General policies for payment procedures that are applicable to all providers are set forth in COMAR 10.09.36.04. B. Medical laboratory providers shall identify the individual who ordered the laboratory services by recording the individual practitioners …

.08 Recovery and Reimbursement. General policies for recovery and reimbursement that are applicable to all providers are set forth in COMAR 10.09.36.07.

.09 Cause for Suspension or Removal and Imposition of Sanctions. General policies governing cause for suspension or removal and imposing sanctions that are applicable to all providers are set forth in COMAR 10.09.36.08.

.10 Appeal Procedures. General policies governing appeal procedures that are applicable to all providers are set forth in COMAR 10.09.36.09.

.11 Interpretive Regulation. General policies governing the interpretive regulations that are applicable to all providers are set forth in COMAR 10.09.36.10.

.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Accrual basis” means recording revenue in the period when earned, regardless of when collected, and recording expenses in the period when incurred, regardless of when paid…

.02 License Requirements. In order to participate in the Program, a provider shall be licensed by the Department, pursuant to Health-General Article, §19-301 et seq., Annotated Code of Maryland, and COMAR 10.07.02, and shall obtain other licenses, as may be required by applicable…

.03 Conditions for Participation. To participate in the Program, the provider shall: A. Be certified by the Department at its total licensed nursing facility bed capacity as meeting the requirements of Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq., for participati…

.04 Covered Services. The Program covers routine care and the following supplies, equipment, and services when appropriate to meet the needs of the recipient: A. Those described in the Maryland Department of Health regulations entitled “Requirements for Long Term Care Facilities”…

.05 Limitations. The following are not covered: A. Services by an out-of-State nursing facility unless the Department and the nursing facility execute a provider agreement; B. Audiology services; C. Services reimbursed under Title XVIII of the Social Security Act; and D. Services…

.06 Preauthorization Requirements. A. The Department of Human Services shall certify the recipient for financial eligibility, and the Department or its designee shall certify the recipient as requiring nursing facility services, except as provided in Regulation .26D of this chapt…

.07 Prospective Rates. A. A provider shall be paid the prospective rate for nursing facility services as defined in Regulation .01B of this chapter plus the Nursing Facility Quality Assessment add-on identified in Regulation .11E of this chapter. B. When necessary, each facility’…

.08 Interim Working Capital Fund. A. A provider may request an allotment from the Interim Working Capital Fund if the facility for which an allotment is requested has not had any of the following deficiencies cited in any survey conducted by the Office of Health Care Quality duri…

.09 Rate Calculation — Administrative and Routine Costs. A. The Administrative and Routine cost center includes: (1) Administrative expenses; (2) Medical records expenses; (3) Training expenses; (4) Dietary; (5) Laundry; (6) Housekeeping; (7) Operation and maintenance; and (8) Ca…

.10 Rate Calculation — Other Patient Care Costs. A. The Other Patient Care cost center includes: (1) Medical director administrative expenses; (2) Pharmacy; (3) Recreational activities; (4) Patient care consultant services; (5) Food cost (unprepared); (6) Social services; and (7)…

.11 Rate Calculation — Capital Costs. A. The Capital cost center includes: (1) Real estate taxes; and (2) Fair rental value. B. Final Capital Cost. (1) The determination of a provider's allowable final Capital per diem rate for the cost items under §A of this regulation is calcul…

.12 Rate Calculation — Nursing Service Costs. A. The Nursing Service cost center includes all nursing expenses related to the direct provision of patient care. B. The Department shall initially establish Nursing Service prices for the rate period January 1, 2015, through June 30,…

.13 Ventilator Care Nursing Facilities. Nursing facilities with licensed nursing facility beds, which have been determined by the Department to meet the standards for ventilator care under COMAR 10.07.02, shall be reimbursed as follows: A. Services for residents receiving ventila…

.14 Pay-for-Performance — Eligibility. In order to be eligible to receive funds through the pay-for-performance program under the provisions of Regulations .15—.19 of this chapter: A. The provider shall be subject to quality assessment under COMAR 10.01.20; and B. During the 1-ye…

.15 Pay-for-Performance — Quality Measures. A. Providers shall receive a composite score based on the following: (1) Staffing levels, as described in §B of this regulation, shall comprise 20 percent of each facility’s score; (2) Staffing stability, as described in §C of this regu…

.16 Pay-for-Performance — Scoring Methodology. A. Facilities that are eligible for pay-for-performance under Regulation .14 of this chapter shall receive a score for each quality measure described in Regulation .15 of this chapter. B. For the quality measures described in Regulat…

.17 Pay-for-Performance — Payment for Improvement. A. In order to be eligible for improvement payment, a facility: (1) Shall meet the eligibility criteria specified in Regulation .14 of this chapter; (2) Shall be eligible and receive a composite score during the current fiscal ye…