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10.09.02.00.htm 10.09.02.00. Title 10 MARYLAND DEPARTMENT OF HEALTH Subtitle 09 MEDICAL CARE PROGRAMS Chapter 02 Physicians' Services Authority: Health-General Article, §2-104(b) 15-103, and 15-105, Annotated Code of Maryland
10.09.02.01.htm 10.09.02.01. 01 Definitions.. A. The following terms have the meanings indicated.. B. Terms Defined.. 1) "Attending physician" means a physician, other than a house officer, resident, intern, or emergency room physician, directly responsible for the patient's care.2) "Board" means the Board of Physician quality Assurance.. 3) "Consultant-specialist" means a licensed physician who meets one of the following criteria:. a) Has been declared board certified by a member board of the American Boar
10.09.02.02.htm 10.09.02.02. 02 License Requirements.. A. The provider shall meet all license requirements as set forth in COMAR 10.09.36.02.. B. A doctor of medicine or osteopathy shall be licensed and legally authorized to practice medicine and surgery in the state in which the service is provided.C. The provider shall ensure that all X-ray or other radiological equipment is inspected and meets the standards established by COMAR 10.14.02 or other applicable standards established by the state in
10.09.02.03.htm 10.09.02.03. 03 Conditions for Participation.. A. General requirements for participation in the Program are that a provider shall meet all conditions for participation as set forth in COMAR 10.09.36.03.B. Specific requirements for participation in the Program as a physicians' services provider require that the provider:1) Shall submit documentation of consultant-specialist status if applying for that status;.
10.09.02.04.htm 10.09.02.04. 04 Covered Services.. The Program covers the following medically necessary services rendered to recipients:. A. Physicians' services rendered in the physician's office, the recipient's home, a hospital, a skilled or intermediate care nursing facility, a freestanding clinic, or elsewhere when these services are:1) Performed by the physician or one of the following:. a) Another licensed physician either in the physician's employ or one who renders services through a
10.09.02.05.htm 10.09.02.05. 05 Limitations.. A. Services which are not covered are:. 1) Physician services not medically justified;. 2) Nonemergency dialysis services related to chronic kidney disorders unless they are provided in a Medicare-certified facility;3) Physician inpatient hospital services rendered during any period that is in excess of the length of stay authorized by the Utilization control agent (UCA)4) Physician services denied by Medicare as not medically necessary;.
10.09.02.06.htm 10.09.02.06. 06 Preauthorization Requirements.. A. The following procedures or services require preauthorization:. 1) Cosmetic surgery;. 2) Contact lens evaluation and fitting;. 3) Lipectomy and panniculectomy;. 4) Transplantations of vital organs;. 5) Services rendered to an inpatient before one preoperative day;. 6) Surgical procedures for the treatment of obesity;. 7) Surgical procedures for the purpose of gender reassignment; and. 8) Elective services from a noncontiguous state..
10.09.02.07.htm 10.09.02.07. 07 Payment Procedures.. A. The provider shall submit the request for payment on the form designated by the Department.. B. The Department reserves the right to return to the provider, before payment, all invoices not properly signed, completed, and accompanied by properly completed forms required by the Department.C. The Provider shall charge the Program the provider’s customary charge to the general public for similar services, except for injectable drugs, the
10.09.02.08.htm 10.09.02.08. 08 Recovery and Reimbursement.. A. If the recipient has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for, or to reimburse the recipient for, services covered by this chapter, the provider shall seek payment from that source first. If an insurance carrier rejects the claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Program. The provider shall submit a
10.09.02.09.htm 10.09.02.09. 09 Cause for Suspension or Removal and Imposition of Sanctions.. A. If the Department determines that a provider, physician, any agent or employee of the provider, or any person with an ownership interest in the provider has failed to comply with applicable federal or State laws or regulations, the Department may initiate one or more of the following actions against the responsible party:1) Suspension from the Program;. 2) Withholding of payment by the Program;.
10.09.02.10.htm 10.09.02.10. 10 Appeal Procedures.. Providers filing appeals from administrative decisions made in connection with these regulations shall do so according to COMAR 10.09.36.09.
10.09.02.11.htm 10.09.02.11. 11 Interpretive Regulation.. Except when the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program recipients without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations.
10.09.02.9999.htm 10.09.02.9999. Administrative History Effective date: July 1, 1967. Amended effective September 1, 1967; October 1, 1967; January 1, 1969; July 1, 1969; December 1, 1969; July 1, 1970; July 1, 1971; January 1, 1976 (2:29 Md. R. 1739)Regulation .22 adopted effective October 13, 1976 (3:21 Md. R. 1206) recodified as Regulation .11 on December 8, 1976 (3:25 Md. R. 1467) ―Existing regulations repealed and new Regulations .01―10 adopted effective December 8, 1976 (3:25 Md. R. 1467)
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