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10.09.94.00.htm 10.09.94.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 94 Special Pediatric Hospitals Authority: Health-General Article, §2-104(b) 15-102.8, 15-103, and 15-105, Annotated Code of Maryland
10.09.94.01.htm 10.09.94.01. 01 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) “Acute hospital” means an institution that provides active, short-term medical diagnosis, treatment, and care.2) “Administrative day” means a day of medical services delivered to a participant who no longer requires the level of care that the provider is licensed to deliver.3) “Admission” means the formal acceptance by a hospital of a participant who is to be provided with
10.09.94.02.htm 10.09.94.02. 02 License Requirements.. A. In order to participate in the Program, a provider shall:. 1) Be licensed by the Department pursuant to Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, as a hospital; and2) Obtain other licenses, as set forth in COMAR 10.07.01.. B. The provider shall ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed, and:
10.09.94.03.htm 10.09.94.03. 03 Conditions for Participation.. A. A provider shall meet all conditions for participation as set forth in COMAR 10.09.36.. B. To participate in the Program as a special pediatric hospital services provider, the provider shall:1) Meet the requirements of Title XIX of the Social Security Act for participation as a hospital, as issued by the U.S. Department of Health and Human Services;2) Directly provide, or make available through contractual arrangements or
10.09.94.04.htm 10.09.94.04. 04 Covered Services.. A. The Program covers the following inpatient services at special pediatric hospitals:. 1) A hospital admission determined to be medically necessary for a participant who is stable enough for transfer to a post-acute setting and requires medical or rehabilitative services that:a) Cannot be provided at a lower level of care; and. b) Meets the medical eligibility criteria under Regulation .06 of this chapter;.
10.09.94.05.htm 10.09.94.05. 05 Limitations.. The Program does not cover:. A. Investigational or experimental hospital services, procedures, or drugs;. B. Inpatient admissions or outpatient visits solely for the administration of injections, unless medical necessity and the participant’s inability to take appropriate oral medications is documented in the participant’s medical record;C. Outpatient visits intended to accomplish one or more of the following:. 1) Prescription drug or food supplement pick-up;.
10.09.94.06.htm 10.09.94.06. 06 Utilization Review.. A. The Department or its designee shall conduct utilization review to determine that special pediatric hospital admissions and outpatient services are authorized only when medically necessary.B. Review Procedure.. 1) For all admissions, the special pediatric hospital shall provide:. a) The elements of a participant’s medical record specified by the Department or its designee for preadmission review, and request to certify the participant’s admission; and
10.09.94.07.htm 10.09.94.07. 07 Payment Procedures.. A. HSCRC Reimbursement Principles.. 1) Except for hospitals reimbursed under the provisions of §B of this regulation and except for administrative days, hospitals located in Maryland that participate in the Program shall charge and be reimbursed according to rates approved by the HSCRC pursuant to COMAR 10.37.03.2) If the Program discontinues using rates which have been approved by HSCRC, the Program shall reimburse a provider:a) According to Medicare
10.09.94.08.htm 10.09.94.08. 08 District of Columbia Hospital Reimbursement.. A. Inpatient Services Base Rate Calculation.. 1) A hospital in the District of Columbia shall:. a) Bill its usual and customary charges; and. b) 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 percentage using only those
10.09.94.09.htm 10.09.94.09. 09 Billing and Reimbursement Principles.. A. The Program shall pay room and board charges for the day of admission, and may not pay room and board charges for the day of discharge from the hospital.B. The provider shall submit a request for payment according to procedures designated by the Department.C. Payments of Medicare Claims.. 1) Payment of Medicare claims is authorized if:. a) The provider accepts Medicare assignment;. b) Medicare makes direct payment to the provider;.
10.09.94.10.htm 10.09.94.10. 10 Recovery and Reimbursement.. A. General policies governing recovery and reimbursement procedures applicable to all providers are set forth in COMAR 10.09.36.07.B. If refund of a payment as specified in §A of this regulation is not made, the Department shall reduce its current payment to the provider by the amount of the duplicate payment, overpayment, or third-party payment.
10.09.94.11.htm 10.09.94.11. 11 Cause for Suspension or Removal and Imposition of Sanctions.. Causes for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08.
10.09.94.12.htm 10.09.94.12. 12 Appeal Procedures.. A provider filing an appeal from an administrative decision made in connection with these regulations shall do so according to COMAR 10.09.36.09.
10.09.94.13.htm 10.09.94.13. 13 Interpretive Regulation.. General policies governing the interpretive regulations that are applicable to providers are set forth in COMAR 10.09.36.10.
10.09.94.9999.htm 10.09.94.9999. Administrative History Effective date: April 10, 2017 (44:7 Md. R. 354).
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