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10.09.06.00.htm 10.09.06.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 06 Hospital Services Authority: Health-General Article, §2-104(b) 15-102.8, 15-103, and 15-105, Annotated Code of Maryland
10.09.06.01.htm 10.09.06.01. 01 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Administrative day" means a day of medical services delivered to a recipient who no longer requires the level of care which the provider is licensed to supply.2) "Admission" means the formal acceptance by a hospital of a patient who is to be provided with room, board, and medically necessary services in an area of the hospital where patients stay at least overnight.
10.09.06.02.htm 10.09.06.02. 02 License Requirements.. A. The provider shall meet all license requirements as set forth in COMAR 10.09.36.02.. B. In order to participate in the Program, a provider shall be licensed by the Department pursuant to Hospital and Related Institutions subtitle, Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, as a hospital, and shall obtain other licenses, as may be required by applicable State and local laws.C. The provider shall ensure that Clinical Laborat
10.09.06.03.htm 10.09.06.03. 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 hospital services provider require that the provider:1) Shall meet the requirements of Title XIX participation as a hospital, as issued by the Department of Health and Human Services;
10.09.06.04.htm 10.09.06.04. 04 Covered Services.. A. The Program covers the following inpatient hospital services:. 1) Medically necessary services for the number of days, per admission, including preoperative days certified by the utilization control agent when these services are:a) Necessary for the provision of diagnostic, curative, palliative, or rehabilitative treatment;. b) Described in the recipient's medical record in sufficient detail to support the invoices submitted for services;
10.09.06.05.htm 10.09.06.05. 05 Limitations.. A. There are limitations placed on the coverage of some hospital inpatient and outpatient services.. B. The Program does not cover:. 1) Inpatient admissions or continuations of stay solely for weight loss or needed rest;. 2) Inpatient admissions or continuations of stay in an acute general hospital solely for occupational therapy, physical therapy, or speech pathology;3) Inpatient admissions or continuations of stay or outpatient visits prima
10.09.06.06.htm 10.09.06.06. 06 Preauthorization Requirements.. A. The following procedures or services require preauthorization:. 1) Inpatient:. a) Cosmetic surgery.. b) Heart transplantation. A heart transplantation for a patient with one of the following contraindications is presumed to be not medically necessary or appropriate, unless otherwise demonstrated according to the provisions of §C of this regulation:i) Active peptic ulcer disease;.
10.09.06.07.htm 10.09.06.07. 07 Preauthorization and Preadmission Requirements.. A. A nonemergency surgical procedure shall be preauthorized by the Program or its designee when performed on a hospital inpatient basis unless:1) The patient is already a hospital inpatient for another condition; or. 2) An unrelated procedure is being done simultaneously which itself requires inpatient hospitalization.B. Nonemergency inpatient hospital admissions require preadmission certification by the Program or its designee.
10.09.06.08.htm 10.09.06.08. 08 Physician Order Entry System.. A. In order to receive payment for claims for services supported by a physician order entry system designed for the electronic entry of physician or other health care practitioner orders, a facility, whether in-State or out-of-State, shall obtain approval of its physician order entry system from the Program.B. To obtain approval of a physician order entry system, a hospital shall submit a written statement signed by the chief exec
10.09.06.09.htm 10.09.06.09. 09 Payment Procedures.. A. Reimbursement Principles.. 1) Hospitals located in Maryland that participate in the Program, except for those hospitals listed in §A(2)3-4) of this regulation, and except for administrative days, shall charge and be reimbursed according to rates approved by the HSCRC pursuant to COMAR 10.37.03.2) The Department will make no direct reimbursement to any State-operated hospital. The Department will claim federal fund recoveries from the U.S. De
10.09.06.10.htm 10.09.06.10. 10 Billing and Reimbursement Principles.. A. Administrative Days. To be paid for administrative days, the provider shall document on forms designated by the Department information which satisfies the conditions listed below:1) The recipient no longer needs acute general, special psychiatric, or other special hospital care, and the following conditions are met:a) The provider has:. i) Implemented a predischarge plan and initiated placement activities for the recipient; and.
10.09.06.11.htm 10.09.06.11. 11 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 c
10.09.06.12.htm 10.09.06.12. 12 Cause for Suspension or Removal and Imposition of Sanctions.. A. If the Department determines that a provider, 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;. 3) Removal from the Program;.
10.09.06.13.htm 10.09.06.13. 13 Appeal Procedures.. A. Except as provided in §B of this regulation, providers filing appeals from administrative decisions made in connection with these regulations shall do so according to [State Government Article, Title 10, Subtitle 2, and Health-General Article, §2-201—2-207, Annotated Code of Maryland] COMAR 10.09.36.09.B. Providers filing appeals of final cost settlements shall do so according to:. 1) Regulation .18 of this chapter; and. 2) COMAR 10.01.09..
10.09.06.14.htm 10.09.06.14. 14 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.
10.09.06.15.htm 10.09.06.15. 15 District of Columbia Hospital Reimbursement.. A. Inpatient Services.. 1) A hospital located in the District of Columbia shall bill its usual and customary charges and shall be reimbursed for covered services the lesser of its percentage of charges as calculated in §A(2) of this regulation or its charges.2) The percentage of charges in §A(1) of this regulation is the product of §A(2)a) (b) (c) and (d) below:a) The cost-to-charges percentage using only those
10.09.06.15-1.htm 10.09.06.15-1. 15-1 District of Columbia Hospital Reimbursement ― Revised Inpatient Methodology.. A. Inpatient Services Rate Calculation.. 1) A hospital in the District of Columbia shall bill its usual and customary charges and shall be reimbursed for covered services the lesser of its percentage of charges as calculated in §A(2) of this regulation or its charges.2) The percentage of charges in §A(1) of this regulation is the product of the following:. a) The cost-to-charges pe
10.09.06.16.htm 10.09.06.16. 16 Submitting Cost Reports.. A. The provider shall submit to the Department or its designee, in the form prescribed, financial and statistical data within 5 months after the end of the provider's fiscal year unless the Department grants the provider an extension or the provider discontinues participation in the Program.B. When reports are not received within 5 months and an extension has not been granted:. 1) For hospitals reimbursed according to Regulation .15 of this chapter, th
10.09.06.17.htm 10.09.06.17. 17 Medical Criteria for Payment for Brain Injury Community-Integrated Programs.. A. In order to be preapproved by the Program for services in a brain injury community-integrated program, a patient shall demonstrate that the patient:1) Suffers from a traumatic brain injury;. 2) Is at low risk of potential medical instability and does not require acute rehabilitation services in a hospital setting;3) Requires an intensive rehabilitation program that provides a multidiscip
10.09.06.18.htm 10.09.06.18. 18 Cost Settlement.. A. The Department or its designee shall notify each provider participating in the Program of the results of the final settlement under Regulation .09B(7) of this chapter.B. Within 60 days after the provider receives the notification described in §A of this regulation, the Department shall pay the amount due to the provider regardless of whether the provider files an appeal.C. The provider may request review of the settlement under Regulation .09B(
10.09.06.9999.htm 10.09.06.9999. Administrative History Effective date: January 1, 1976 (2:29 Md. R. 1740). Regulations .01, .03 and .07 amended as an emergency provision effective July 1, 1977 (4:15 Md. R. 1142) temporary status extended at 4:17 Md. R. 1291; amended permanently effective October 21, 1977 (4:22 Md. R. 1671)Regulations .03 and .04 amended as an emergency provision effective April 1, 1977 (4:8 Md. R. 630) amended permanently effective August 17, 1977 (4:17 Md. R. 1299)Regulation .05 adopted as
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