Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 14 - CANCER CONTROL
Chapter 10.14.02 - Reimbursement for Breast and Cervical Cancer Diagnosis and Treatment
Section 10.14.02.12 - Medical Laboratory Services
Universal Citation: MD Code Reg 10.14.02.12
Current through Register Vol. 51, No. 19, September 20, 2024
A. To be considered a participating medical laboratory in the Program, the provider shall:
(1) Be in compliance with the
applicable license requirements for a medical laboratory providing services for
Maryland residents including, but not limited to:
(a) Requirements for Medicare certification;
(b) Compliance with the
requirements pursuant to COMAR
10.10.03.01 if operating in
Maryland; and
(c) Requirements for
the Federal Clinical Laboratory Improvement Act of 1988,
42 U.S.C. § 263a;
(2) Agree to accept as payment in full for
the reimbursed service, the amount paid by the Program as specified in §E
of this regulation plus, if applicable, the amount paid by the eligible
patient's health insurer and the patient contribution amount;
(3) Agree not to bill an eligible patient for
an additional charge for the medical laboratory services provided;
(4) Abide by the provisions set forth in this
regulation by signing and sending to the Department the designated Departmental
form;
(5) Place no restriction on
the eligible patient's right to select a provider; and
(6) Maintain records adequate to substantiate
the ordering, performance, and reporting of laboratory procedures performed or
referred for a minimum of 6 years, and, upon request, allow the Department
access to the records.
B. A reimbursed service includes but is not limited to the following:
(1) Preparation,
analysis, and interpretation of a cervical biopsy, endometrial biopsy, vaginal
biopsy, and breast biopsy; and
(2)
A laboratory procedure or service related to the diagnosis and treatment of
breast cancer, cervical cancer, or a precancerous cervical lesion.
C. A non-reimbursed service includes but is not limited to the following:
(1) A laboratory service not directly related
to the diagnosis and treatment of breast cancer, cervical cancer, or a
precancerous cervical lesion;
(2) A
service for which there does not exist an order signed by a participating
health care provider;
(3) A
procedure for which the laboratory has not been certified by
Medicare;
(4) A service not
provided according to the laws and regulations of the jurisdiction in which the
service is rendered;
(5) A
procedure that is investigational or experimental in nature; and
(6) A service included and paid for by the
Program as part of the total charge submitted by an inpatient facility or
hospital outpatient department.
D. Reimbursement Procedures. The participating medical laboratory is responsible for:
(1) Submitting a bill for the reimbursed
service provided on the form designated by the Department within 12 months of
the date of service as follows:
(a) If an
eligible patient is uninsured or has insurance that does not provide coverage
for the reimbursed service, the participating medical laboratory shall send the
bill to the Department; or
(b) If
an eligible patient is covered by Medicare or other insurance, the
participating medical laboratory shall bill:
(i) Medicare or the other insurance for the
service ; and
(ii) The Department
for the outstanding deductible and patient contribution amount; and
(2) Keeping in the
records, for each invoice, a copy of the signed orders from a participating
health care provider requesting the service.
E. Payment Procedures.
(1) The Department shall pay the
participating medical laboratory for a reimbursed service:
(a) Pursuant to COMAR
10.09.09.07E for
an eligible patient who is uninsured or has insurance that does not provide
coverage for the reimbursed service; or
(b) Pursuant to COMAR
10.09.09.07F and
G(1) and 100 percent of co-insurance for an approved procedure for an eligible
patient who is covered by Medicare.
(2) The Department may not reimburse for:
(a) Completion of a form or report;
(b) A broken or missed appointment;
and
(c) A service which is normally
provided at no charge.
F. The Program shall reimburse for claims pursuant to this regulation as set forth in Regulation .21 of this chapter.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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