Current through Register Vol. 51, No. 19, September 20, 2024
A. Payment
for free-standing urgent care centers is as follows:
(1) Urgent care centers are reimbursed a
facility fee, which is determined by the Program;
(2) In addition to the facility fee, the
Program shall reimburse for services rendered by the physician, nurse
practitioner, or physician assistant during the visit at the free-standing
urgent care center; and
(3) If the
service is free to individuals not covered by Medicaid:
(a) The provider:
(i) May charge the Program; and
(ii) Shall be reimbursed in accordance with
the provisions of this regulation; and
(b) The provider's reimbursement is not
limited to the provider's customary charge.
B. Reimbursement by the Program for facility
services, which are included in the facility fee, includes:
(1) Nursing, technician, and related
services;
(2) Use of the
center;
(3) Drugs, biologicals,
surgical dressings, supplies, splints, casts, and appliances, and any equipment
directly related to the treatment of the illness or injury; and
(4) Administrative costs.
C. The Department shall pay for
covered services at the lesser of:
(1) The
provider's customary charge to the general public unless the service is free to
individuals not covered by Medicaid, or
(2) The Department's fee for:
(a) Professional services in accordance with
COMAR 10.09.02.07D;
and
(b) Laboratory services in
accordance with COMAR
10.09.09.07D.
D. The
provider shall submit a request for payment as set forth in COMAR
10.09.36.04A.
E. The Program reserves the right
to return to the provider, before payment, all invoices that are not properly
completed.
F. The Program shall
authorize payment on Medicare claims only if:
(1) The provider accepts Medicare
assignment;
(2) Medicare makes
direct payment to the provider;
(3)
Medicare has determined that the services are medically necessary;
(4) Services are covered by the Program;
and
(5) Initial billing is made
directly to Medicare according to Medicare guidelines.
G. The Department shall make supplemental
payment on Medicare claims subject to the limitations of the State budget and
the following provisions:
(1) Deductible
insurance shall be paid in full;
(2) Beginning with August 1, 2010 dates of
service, coinsurance shall be paid:
(a) In
full for the following:
(i) Mental health
services;
(ii) CPT codes that are
priced by report;
(iii) Claims for
anesthesia services;
(iv) Claims
from a federally qualified health center; and
(v) HCPCS codes beginning with A through W;
and
(b) For all other
claims, at the lesser of:
(i) 100 percent of
the coinsurance amount; or
(ii) The
balance remaining after the Medicare payment is subtracted from the Medicaid
rate; and
(3)
Services not covered by Medicare, but considered medically necessary by the
Program, will be paid according to the limitations of Regulation .04 of this
chapter.
H. The provider
may not bill the Program for:
(1) Completion
of forms and reports;
(2) Broken or
missed appointments; or
(3)
Professional services rendered by mail or telephone.
I. The Program may not make a direct payment
to a participant.
J. Billing time
limitations for claims submitted under this chapter are set forth in COMAR
10.09.36.06A.
