Current through Register Vol. 51, No. 19, September 20, 2024
A. A trauma physician:
(1) Is eligible for payment from the Fund for
trauma services provided to uncompensated trauma care patients with an
admission date on the Maryland Trauma Registry beginning on or after July 1,
2006; and
(2) May seek
reimbursement in accordance with this regulation.
B. The cost of uncompensated care incurred by
a trauma physician in providing trauma care to a trauma patient as defined in
this chapter shall be reimbursed at a rate of up to 100 percent of the current
Medicare facility-based payment for a service in the Baltimore carrier locality
area, less any amount for trauma physician services paid by the patient or
other third-party payors including, but not limited to, auto insurance,
criminal injuries compensation fund, attorneys, or collection agencies, as
reported to the Fund on the uncompensated services claim.
C. An organization billing on behalf of
physicians eligible for uncompensated care payments shall:
(1) Designate a trauma service by appropriate
coding of the CPT Modifier on the electronic ANSI 837 transaction or paper CMS
1500 claim in accordance with claims submission requirements; and
(2) Include the patient's trauma registry
number on the electronic claim or on the CMS 1500.
D. Diagnosis Code.
(1) Except as provided in §D(2) of this
regulation, a diagnosis code shall fall between 800.00-959.9.
(2) If a diagnosis code does not fall between
800.0-959.9, a supplementary classification of external causes of injury and
poisoning (E800-E999) shall appear as a secondary diagnosis code.
E. To be eligible for
uncompensated care differential payment described in §B of this
regulation, the place of service code shall have one of the following values:
(1) Appropriate code for "acute care
inpatient hospital";
(2)
Appropriate code for "outpatient hospital";
(3) Appropriate code for "emergency room";
or
(4) Appropriate code for
"rehabilitation hospital".
F. The uncompensated services claim shall:
(1) Document uncompensated care services not
previously claimed under the Fund;
(2) Exclude services for trauma patients who
have applied for assistance through Medicaid, but who have not received a final
eligibility determination;
(3)
Exclude noncovered services that the trauma physician provided to trauma
patients covered by health insurance; and
(4) Exclude services for trauma patients
covered by health insurance for which the physician failed to comply with the
insurer's coverage rules or claim filing requirements.
G. Uncompensated care services are eligible
for reimbursement from the Fund only after a faculty practice plan, a physician
practice plan, a trauma center on behalf of a trauma physician, or an
individual trauma physician has completed its collection efforts using the
respective entity's documented policies and procedures.
H. Order of Preference.
(1) To minimize administrative costs in
administering the Fund, the order of preference for the entity submitting an
uncompensated services claim is as follows:
(a) Faculty practice plan;
(b) Physician practice;
(c) Trauma physician.
(2) The preference specified in §H(1) of
this regulation refers to the submitting entity and not the preference for
distributing payments.
I. A trauma patient treated at an
out-of-State pediatric trauma center that has entered into an agreement with
MIEMSS shall be a Maryland resident in order for the trauma physician to file
an uncompensated services application for an uncompensated care shortfall
payment. The determination of whether a trauma patient is a Maryland resident
shall be based on the trauma patient's demographic information as listed on the
Maryland Trauma Registry.
J. The
uncompensated services claim shall contain the following information:
(1) The name and federal tax identification
number of the trauma physician rendering the care;
(2) The date of the service;
(3) Appropriate codes describing the
service;
(4) Any amount recovered
for the service rendered;
(5) The
name of the trauma patient;
(6) The
trauma patient's Maryland Trauma Registry number;
7) Date of the original trauma
injury;
(8) The diagnosis codes
that were treated;
(9) The
procedure and service codes performed; and
(10) Other information requested in the
claim.
K. The
Commission, in consultation with the Health Services Cost Review Commission,
may establish a payment rate for uncompensated care incurred by a trauma
physician in providing trauma care to trauma patients that is above the 100
percent of Medicare payment for the service if:
(1) The Commission determines that increasing
the payment rate above 100 percent of the Medicare payment for the service will
address an unmet need in the State trauma system;
(2) The source of revenue increases and the
projected current uses of the Fund decline;
(3) The Commission considers data analyses of
trauma care rendered at Maryland trauma centers for CPT codes reimbursed as
uncompensated care as reported to the Maryland Medical Care Data Base;
and
(4) The Commission reports on
its intention to increase the payment rate to the Senate Finance Committee and
the House Health and Government Operations Committee, at least 60 days before
any adjustment to the rate.
