Current through Register Vol. 51, No. 19, September 20, 2024
A. The Program shall pay room and board
charges for the day of admission, and may not pay room and board charges for
the day of discharge from the hospital.
B. The provider shall submit a request for
payment according to procedures designated by the Department.
C. Payments of Medicare Claims.
(1) Payment of Medicare claims is authorized
if:
(a) The provider accepts Medicare
assignment;
(b) Medicare makes
direct payment to the provider;
(c)
Medicare determined that services were medically necessary;
(d) The services are covered by the Program;
and
(e) Initial billing is made
directly to Medicare according to Medicare guidelines.
(2) Payment of a deductible and co-insurance
related to Medicare claims shall be paid subject to the HSCRC discounts, except
in the case of a participant receiving hospital services in an out-of-State
facility, in which case deductible and co-insurance shall be paid in
full.
D. Out-of-State
Hospital Reimbursement.
(1) The Program shall
reimburse hospitals outside of Maryland, excluding the District of Columbia, at
a rate that is 100 percent of the amount reimbursable by the host state's Title
XTK agency or the amount of the hospital's actual charges in total, whichever
is less.
(2) Out-of-State providers
are responsible for reimbursing the Department for overpayments, in accordance
with Regulation .10 of this chapter.
E. Payment for Administrative Days.
(1) The provider shall document, on forms
designated by the Department, information that satisfies the conditions stated
in Regulation .06C of this chapter.
(2) The provider shall:
(a) Receive determination from the Department
or its designee that the participant no longer requires the level of care that
the special pediatric hospital is licensed to provide;
(b) Receive determination from the Department
or its designee that the participant requires services at a lower level of
acuity, and a bed in an appropriate facility is not available; and
(c) Notify the Department or its designee of
discharge planning before the termination of the need for inpatient
hospitalization at the level the facility is licensed to provide, and obtained
a level of care determination from the agent.
F. During the period of administrative days,
the Department or its designee shall review the documentation in increments of
not more than 14 days.
G. For
participants who are not ventilator-dependent, payment for approved
administrative days shall be the lesser of:
(1) An estimated Statewide average Medicaid
nursing home payment rate as determined by the Department; or
(2) If the hospital has a unit which is a
skilled nursing facility, the allowable costs in effect under Medicare or
extended services provided to participants of the unit.
H. The Department will make no direct payment
to the participant.
I. Billing time
limitations for claims submitted pursuant to this chapter are set forth in
COMAR 10.09.36.06.
J. The
Department reserves the right to return to the provider, before payment, all
invoices not properly completed.
K.
Noncompliance with the Program's requirements as determined by the Department
or its designee shall result in nonpayment of the claim.
L. Payment on claims to a hospital located in
the District of Columbia shall be reduced by a quarterly claims processing fee
of 6 percent.
