Current through Register Vol. 51, No. 19, September 20, 2024
A. The provisions of COMAR
10.09.24.14A
concerning fraud apply to this chapter.
B. The Department shall make a claim against
income or resources, or both, of a recipient for benefits correctly paid, or to
be paid, under the circumstances specified in COMAR
10.09.24.15A
-1.
C. The Department may impose a lien on the
property of a recipient under the circumstances specified in COMAR
10.09.24.15A
-2(1).
D. The Department shall seek recovery of
Medical Assistance benefits correctly paid as provided in COMAR
10.09.24.15A
-3.
E. The Department shall accept reimbursement
if voluntarily offered by a current or former recipient or by someone acting on
behalf of the current or former recipient.
F. Extended Benefits Pending a Hearing
Decision.
(1) The Department shall refer for
reimbursement consideration all cases in which:
(a) A recipient received extended benefits
pending a hearing and decision by the hearing officer; and
(b) The hearing officer affirmed the decision
of the Department that was the subject of the appeal.
(2) The Department:
(a) Shall institute procedures to recover the
cost of any expenditures made on behalf of a recipient in cases identified in
§F(1) of this regulation; and
(b) May not apply §F(2)(a) of this
regulation to an individual who requested a hearing and extended benefits based
on a bona fide belief that the adverse action was erroneous.
G. The Department shall
refer for investigation and other appropriate action all cases in which a
recipient has received coverage erroneously as a result of the action or
inaction of the recipient, representative, or individual acting responsibly for
the recipient.
H. The Department
shall investigate and take appropriate action in all cases in which eligibility
has been incorrectly established as a result of the action or inaction of a
recipient, representative, or individual acting responsibly for the
recipient.
I. Providers.
(1) If a recipient has ESI or other coverage,
or if any other individual is obligated, either legally or contractually, to
pay for, or to reimburse the recipient for, services covered by this chapter, a
provider of covered services shall seek payment from that source before
submitting a claim to the Medical Assistance Program.
(2) If an insurance carrier rejects the
provider's claim or pays less than the amount allowed by the Medical Assistance
Program, the provider may submit a claim to the Medical Assistance Program,
which shall be accompanied by a copy of the insurance carrier's notice or
remittance advice.
(3) If payment
is made by both the Medical Assistance Program and the insurance or other
source for the same service, the provider shall refund to the Department,
within 60 days of receipt, the amount paid by the Medical Assistance Program or
the insurance or other source, whichever is less.
(4) A provider shall reimburse the Department
for any overpayment.
J.
Recipients. A recipient shall assist and cooperate with the Department's
efforts to collect available health insurance benefits and other third party
payments by:
(1) Completing a form designated
by the Department to report all pertinent information to assist the Department
in seeking reimbursement for services provided;
(2) Notifying the Department within 10 days
if medical treatment has been provided as a result of any accident or other
occurrence in which a third party may be liable for health care services
provided to the recipient; and
(3)
Providing to the Department, as set forth in §J(2) of this regulation, the
information required under such circumstances pursuant to COMAR
10.09.24.12 and Regulation
.09B(1)(d) of this chapter.
