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10.09.05.00.htm 10.09.05.00. Title 10 MARYLAND DEPARTMENT OF HEALTH Subtitle 09 MEDICAL CARE PROGRAMS Chapter 05 Dental Services Authority: Health-General Article, §2-104(b) 15-103, and 15-105, Annotated Code of Maryland
10.09.05.01.htm 10.09.05.01. 01 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Adverse action" means any action taken by the administrative services organization (ASO) to deny, reduce, terminate, delay, or suspend a covered service.2) "Aftercare" means the period of follow-up care after initial services are rendered, during which any additional related services rendered by the same provider are included in the payment for the original services.
10.09.05.02.htm 10.09.05.02. 02 License Requirements.. A. The provider shall meet all license requirements as set forth in COMAR 10.09.36.02.. B. A dentist shall be licensed and legally authorized to practice dentistry in the state in which service is provided.C. All dentists and dental hygienists working for a mobile dental unit shall be currently licensed and registered with the Maryland Board of Dental Examiners.D. The driver of the mobile dental unit:.
10.09.05.03.htm 10.09.05.03. 03 Provider Qualifications and 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 dental provider requires that the provider:1) Meets the licensure requirements as provided in Regulation .02 of this chapter; and. 2) Not knowingly employ another person to provide services to Medical Assis
10.09.05.04.htm 10.09.05.04. 04 Covered Services.. A. The Program covers the following medically necessary dental services for participants younger than 21 years old, and effective January 1, 2017, eligible former foster care participants younger than 26 years old, including but not limited to the following:1) Emergency, preventive, diagnostic, and treatment services;. 2) Semiannual cleaning, fluoride treatment and examination;. 3) Pit and fissure sealants for the occlusal surfaces of posterior permanen
10.09.05.05.htm 10.09.05.05. 05 Limitations.. A. The Program places the following limitations upon covered services:. 1) Reimbursement for a complete radiographic survey or full series of X-rays of the mouth may not be made more frequently than once every 3 years to the same provider, or in the case of a group practice, to any partner or associate of that practice, unless medically necessary or specifically required or requested by the Program.2) For any traumatic injury case, a provider may b
10.09.05.06.htm 10.09.05.06. 06 Preauthorization Requirements.. A. Preauthorization is issued when:. 1) Program procedures are met;. 2) Program limitations are met; and. 3) The provider submits to the Department, adequate documentation demonstrating that the service to be preauthorized is medically necessary.B. Preauthorization is required for the following:. 1) Resin fused to metal crown;. 2) Porcelain fused to metal crown;. 3) Nonprecious metal crown (full cast). 4) Apicoectomies and periradicular services;.
10.09.05.07.htm 10.09.05.07. 07 Payment Procedures.. A. To obtain compensation from the Department for covered services, the provider shall submit a request for payment on the form designated by the Department with the following data or attachments:1) If applicable, the preauthorization number shall be inserted in the designated appropriate field on the invoice claim form;2) If applicable, pathology reports shall be attached to the claim form; and. 3) If applicable, comprehensive narratives shall b
10.09.05.08.htm 10.09.05.08. 08 Recovery and Reimbursement.. A. If the participant has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for or to reimburse the participant 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
10.09.05.09.htm 10.09.05.09. 09 Cause for Suspension or Removal and Imposition of Sanctions.. A. If the Department determines that a provider, dentist, 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 Department;.
10.09.05.10.htm 10.09.05.10. 10 Appeal Procedures.. A. Providers may exercise appeal rights pursuant to State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland.B. Appeals shall be filed within 30 days of receipt of notice of administrative decisions.. C. The provider may appeal a decision to the Office of Administrative Hearings as specified in COMAR 10.09.36.09.
10.09.05.11.htm 10.09.05.11. 11 Interpretive Regulation.. Except when the language of a specific regulation indicates an attempt by the Department to provide reimbursement for covered services to Program participants without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations.
10.09.05.9999.htm 10.09.05.9999. Administrative History Effective date: January 1, 1976 (2:29 Md. R. 1740). Regulations .01―10 amended effective October 13, 1976 (3:21 Md. R. 1206). Regulations .01I, .04A, .05, and .06B amended as an emergency provision effective February 1, 1982 (9:2 Md. R. 110) emergency status extended at 9:11 Md. R. 1122 and 9:17 Md. R. 1697 (Emergency provisions are temporary and are not printed in COMAR)Regulation .06C adopted effective April 4, 1980 (7:7 Md. R. 708).
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