Maryland Administrative Code

.09 Appeal Procedures. Appeal procedures shall be as set forth in COMAR 10.09.36.09.

.10 Interpretive Regulation. State regulations shall be interpreted as 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) “Administrative service organization (ASO)” has the meaning stated in COMAR 10.09.59.01. (2) “ASO system” means the electronic system available to providers which the ASO u…

.02 Licensing Requirements. A. A PRP serving adults and participating as a health home shall be approved pursuant to COMAR 10.63.03.09. B. A PRP serving minors and participating as a health home shall be approved pursuant to COMAR 10.63.03.10. C. An MTS program participating as a…

.03 Participant Eligibility. A. An individual is eligible for health home services if the individual: (1) Is a recipient of Maryland Medical Assistance; and (2) Meets the following criteria: (a) Receives outpatient mental health rehabilitation or treatment services with a PRP or …

.04 Conditions for Health Home Provider Participation. To be eligible as a health home, a provider shall: A. Meet the conditions for provider participation in the Medical Assistance Program, as set forth in COMAR 10.09.36.03; B. Meet the approval requirements set forth in Regulat…

.05 Health Home Provider Staff. A. Health Home Staffing Requirements. (1) Health Home Care Manager. (a) At minimum, the health home shall maintain health home care manager staff at a ratio of .5 FTE per 125 participants. (b) Up to a staffing level of 1 FTE, the health home care m…

.06 Covered Services. A. The Department covers the services in §§B—G of this regulation when these services have been documented, pursuant to the requirements in this chapter, as necessary. B. Comprehensive Care Management. The health home shall collaborate to provide comprehensi…

.07 Health Home Participant Flow. A. Enrollment. (1) The health home shall enroll an individual only after the individual has been enrolled in the health home provider's applicable PRP, MTS, or OTP services. (2) During enrollment, an OTP established as a health home shall identif…

.08 Limitations. A. An eligible individual may not receive services from a health home provider that is not the individual’s PRP, MTS, or OTP provider. B. Health home services do not restrict or otherwise affect: (1) Eligibility for Title XIX benefits or other available benefits …

.09 Payment Procedures. A. The Department shall reimburse the health home for covered services according to the requirements in this chapter and the rate established in §C of this regulation. B. Request for Payment. (1) The health home provider is authorized to bill for the intak…

.10 Recovery and Reimbursement. Recovery and reimbursement shall be as set forth in COMAR 10.09.36.07.

.11 Cause for Suspension or Removal and Imposition of Sanctions. A. Cause for suspension or removal from the Medical Assistance Program and imposition of sanctions shall be as set forth in COMAR 10.09.36.08. B. If the Department determines that a health home provider has failed t…

.12 Appeal Procedures. Appeal procedures shall be as set forth in COMAR 10.09.36.09.

.13 Interpretive Regulation. State regulations shall be interpreted as 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) “Behavioral plan” means an individualized written plan for therapeutic behavioral services which includes the components specified in Regulation .03B(1) of this chapter. (2…

.02 Conditions for Provider Participation. A. A therapeutic behavioral service provider shall: (1) Ensure that therapeutic behavioral aides are trained and supervised in: (a) Principles of behavior change and childhood development; (b) Clinically accepted techniques for decreasin…

.03 Covered Services. A. The Program covers the services listed in this chapter when the services are: (1) Diagnosed, identified, and prescribed by an EPSDT provider to be medically necessary; (2) Preauthorized by the Department or its designee; and (3) Delivered in accordance wi…

.04 Limitations. A. To be eligible for therapeutic behavioral services the: (1) Participant shall be younger than 21 years old and enrolled in the Program; (2) Participant shall be assessed as having behaviors or symptoms related to a mental health diagnosis that places the indiv…

.05 Preauthorization. A. The Department or its designee shall require preauthorization for therapeutic behavioral services. B. The initial authorization shall be given for not more than 60 calendar days. C. Additional authorization beyond the initial authorization shall be reques…

.06 Payment Procedures. A. Request for payment of services shall be submitted in accordance with COMAR 10.09.36.04. B. Billing time limitations for claims submitted pursuant to this chapter as set forth in COMAR 10.09.36.06. C. Reimbursement for services covered under this chapte…

.07 Recovery and Reimbursement. Recovery and reimbursement shall be as set forth in COMAR 10.09.36.07.

.08 Cause for Suspension or Removal and Imposition of Sanctions. Causes for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08.

.09 Appeal Procedures. Appeals procedures shall be as set forth in accordance with COMAR 10.09.36.09.

.10 Interpretive Regulation. This chapter shall be interpreted as 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) “Attending physician” means: (a) A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State; or (b) A nurse practitioner who meets …

.02 Licensing Requirements. A. In order to participate in the Program, a provider shall be licensed by the Department pursuant to Health-General Article, Title 19, Subtitle 9, Annotated Code of Maryland, or shall be legally authorized to provide hospice care in the jurisdiction i…

.03 Conditions of Participation. A. General requirements for participation in the Program are that providers shall: (1) Meet all conditions for participation as set forth in COMAR 10.09.36.03, except as otherwise specified in this regulation; and (2) Ensure that the licensure req…

.04 Duration of Hospice Care. A. An individual may elect to receive hospice care during one or more of the following election periods: (1) An initial 90-day period; (2) A subsequent 90-day period; or (3) An unlimited number of subsequent 60-day periods. B. The periods of care ind…

.05 Eligibility for and Election of Hospice Care. A. To be eligible for hospice care, written certification of terminal illness shall be obtained by the hospice for each of the election periods listed in Regulation .04 of this chapter. Procedures for certification of terminal ill…

.06 Covered Services. A. Hospice care includes the services listed in §B of this regulation when the services are: (1) Provided to an eligible recipient who elects hospice care, in accordance with Regulation .05 of this chapter; (2) Reasonable and necessary for the palliation or …

.07 Limitations. When a recipient is enrolled in Medicare Part A, Program payment for hospice care shall be limited to payment of the recipient's Medicare hospice care co-insurance amounts for drugs and biologicals and for respite care and, where applicable, room and board for re…

.08 Payment Procedures. A. Reimbursement Principles. (1) The Program shall pay the provider at one of four rate categories for each day that the participant is under the provider's care, subject to the conditions, limitations, and exceptions set forth in this chapter. (2) The pay…

.09 Recovery and Reimbursement. Recovery and reimbursement shall be as set forth in COMAR 10.09.36.07.

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

.11 Appeal Procedures. Appeal procedures for providers shall be as set forth in COMAR 10.09.36.09.

.12 Interpretive Regulation. State regulations shall be interpreted as set forth in COMAR 10.09.36.10.

.01 Definitions. A. The following terms apply to Medical Assistance providers. Additional defined terms, unique to Medical Assistance provided services, are found in Medical Assistance service-specific chapters. B. Terms Defined. (1) “Abandoned” means failing to appear for a hear…

.02 License Requirements. Medical Assistance Program providers shall, to the extent required by law, be licensed, certified, or otherwise legally authorized to practice or deliver services in the state in which the service is provided. Cross References 10.09.06.03A 10.09.21.03A 1…

.03 Conditions for Participation. A. To participate in the Program, the provider shall: (1) Ensure compliance with all the Medical Assistance provisions listed in the Code of Maryland Regulations (COMAR) designated for their provider type; (2) Apply for participation in the Progr…

.03-1 Conditions for Participation — Home and Community-Based Settings. A. Providers of services under COMAR 10.09.84 shall comply with the provisions of §§D—F of this regulation and 42 CFR 441.301(c)(4). B. Effective January 1, 2018, to be enrolled as a provider of services auth…

.03-2 Conditions for Participation — Data Management Systems and Electronic Visit Verification. A. This regulation establishes standards for providers using Data Management systems. B. Definitions. (1) In this regulation, the following terms have the meanings indicated. (2) Terms…

.04 Payment Procedures. A. The provider shall submit the request for payment of services rendered according to procedures established by the Department and in the format designated by the Department. B. The Department reserves the right to return to the provider, before payment, …

.05 Cost Reporting. A. Providers who are reimbursed on the basis of cost reports shall submit to the Department or its designee, in the form prescribed, financial and statistical data within 3 months after the end of the provider's fiscal year unless the Department grants the pro…

.06 Billing Time Limitations. A. Definition. (1) In this regulation, the following term has the meaning indicated. (2) Term Defined. “Received” means: (a) The Program taking delivery of a claim after the Program signs a certified mail, return receipt requested parcel from the Uni…

.07 Recovery and Reimbursement. A. If the participant has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for, or to reimburse the participant for, covered services, the provider shall seek payment from that source first. …

.08 Cause for Suspension or Removal and Imposition of Sanctions. A. If the Department determines that a provider, any agent or employee of the provider, or any person with an ownership interest in the provider or related party of the provider has failed to comply with applicable …