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10.11.03.00.htm 10.11.03.00. Title 10 MARYLAND DEPARTMENT OF HEALTH Subtitle 11 MATERNAL AND CHILD HEALTH Chapter 03 Children's Medical Services Program Authority: Health-General Article, §15-125, Annotated Code of Maryland
10.11.03.01.htm 10.11.03.01. 01 Incorporation by Reference.. In this chapter, the federal poverty guidelines, as amended, which are updated periodically in the Federal Register by the U.S. Department of Health and Human Services, are incorporated by reference.
10.11.03.02.htm 10.11.03.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Agency" means a legally incorporated body or governmental unit which provides services to disabled children or their families, or both.2) "Allowable cost" means the maximum amount which the Program will reimburse for the drug or product portion of the prescription.3) “Appeal” means the process by which a child with special health care needs, as defined in §B(9) o
10.11.03.03.htm 10.11.03.03. 03 Covered Services.. A. The CMS Program shall authorize covered services when a CMP has been approved.. B. The CMP shall:. 1) Include:. a) All diagnoses or suspected diagnoses;. b) Service requested or provided;. c) Specific reason for the service request;. d) Evaluation or treatment findings;. e) Follow-up plans related to the service provided by the CMS Program;. f) Source of primary health care; and. 2) Be reviewed and approved by the CMS Program..
10.11.03.04.htm 10.11.03.04. 04 Rights and Responsibilities.. A. Applicant.. 1) The applicant shall furnish factual information regarding the applicant’s eligibility, and shall keep the CMS Program informed of any change in demographic, financial, medical, or insurance coverage status.2) An eligible applicant shall use only Medical Assistance approved providers.. 3) An applicant shall complete a Medical Assistance application when the applicant is considered potentially eligible.1) An applicant who meets
10.11.03.05.htm 10.11.03.05. 05 General Eligibility Criteria.. A. To be eligible for the CMS Program’s services, an applicant shall:. 1) Submit a completed, signed, and dated CMS Program application;. 2) Provide documentation of:. a) State residency, as this program is not meant to cover those whose sole purpose in coming to Maryland is to obtain medical care or coverage; andb) Being younger than 22 years old;. 3) Provide a form of identification for the applicant and the applicant’s parents or guardians if th
10.11.03.06.htm 10.11.03.06. 06 Medical Eligibility.. A. Children with special health care needs may be eligible for services covered by the CMS Program.. B. Chronic medical conditions which may render an applicant medically eligible include, but are not limited to, the following:1) Chronic asthma;. 2) Chronic renal disease;. 3) Cystic fibrosis;. 4) Diabetes and other endocrine disorders;. 5) Hemophilia;. 6) Immune deficiencies;. 7) Juvenile rheumatoid arthritis;. 8) Leukemia and other childhood cancers;.
10.11.03.07.htm 10.11.03.07. 07 Financial Eligibility.. A. An applicant's financial eligibility is based upon the composition and income of the family unit.. B. Family Unit. A family unit consists of one or more of the following members residing in the same household:1) The applicant;. 2) The natural or adoptive parents, stepparents, or legal guardian if the applicant is unmarried;. 3) The unmarried natural or adoptive siblings of the applicant who are younger than 22 years old;.
10.11.03.08.htm 10.11.03.08. 08 Application Process.. A. The CMS Program shall make applications available to, but which are not limited to, the following agencies:1) Local health department;. 2) Admitting, social services, or business office of a participating hospital;. 3) Cooperating agencies; and. 4) An applicant, upon request.. B. Completion of Application.. 1) An applicant, the applicant's parent, guardian, or representative shall submit a complete, signed application approved by 2) A parent of any age, o
10.11.03.09.htm 10.11.03.09. 09 Disposition of Application.. A. General.. 1) The CMS Program professional staff shall:. a) Review individual applications;. b) Determine CMS Program eligibility and services to be approved for payment by the CMS Program within 30 calendar days of receipt of the complete application;c) Verify the information provided by an applicant which may include an interview:. i) With the applicant if the applicant is 18 years old or older, or with the applicant’s parent or guardian; and
10.11.03.10.htm 10.11.03.10. 10 Record Retention and Confidentiality.. A. Records.. 1) A provider shall:. a) Retain and reproduce, upon request for a minimum of 6 years, records and reports required by the Department for the administration of services; andb) Be responsible for maintaining patient records for services that it provides in accordance with the approved Department retention schedule.2) Records referred to in §A(1) of this regulation include:. a) Documentation of personal interviews;.
10.11.03.11.htm 10.11.03.11. 11 General Conditions of Provider Participation.. A. A provider of services which are covered by the CMS Program shall comply with the following general requirements:1) For fee for service reimbursement, be approved by Medical Assistance in writing as a Medical Assistance provider;2) For copay and deductible reimbursement, be a participating provider with the insurance plan purchased by the CMS Program f3) Request preauthorization on the forms designated by the CMS Program;.
10.11.03.12.htm 10.11.03.12. 12 Conditions of Hospital Participation.. A hospital shall:. A. Comply with all relevant State and federal requirements related to the provision of health services and the receipt of funds;B. Be licensed by the Department pursuant to the Hospital and Related Institutions subtitle, Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, as a hospital, and be licensed, as may be required, by other applicable State and local laws;
10.11.03.13.htm 10.11.03.13. 13 General Billing Procedures.. A. A provider shall accept payment at the Medical Assistance rate as payment in full.. B. A provider shall submit:. 1) Requests for payment on the form designated by the CMS Program; and. 2) Completed reports and attachments as requested by the CMS Program.. C. A provider may not bill the CMS Program for:. 1) Completion of forms and reports;. 2) Broken or missed appointments;. 3) Professional services rendered by mail or telephone; and.
10.11.03.14.htm 10.11.03.14. 14 Billing Procedures for Physician Office Services.. A. A physician shall:. 1) Comply with all procedures listed in Regulation .13 of this chapter;. 2) Charge the CMS Program the usual and customary charge to the general public for similar services; and3) Bill the CMS Program as specified by the CMS Program.. B. The CMS Program shall:. 1) Use the fee schedule contained in the Maryland Medical Assistance Program’s Professional Services Provider Manual and Fee
10.11.03.15.htm 10.11.03.15. 15 Billing Procedures for Medically Necessary Dental Services.. A. A dentist shall comply with all procedures listed in Regulation .13 of this chapter.. B. The CMS Program shall:. 1) Cover approved diagnostic, restorative, and preventive treatment as described in the CMP; and. 2) Preauthorize estimates of costs..
10.11.03.16.htm 10.11.03.16. 16 Billing Procedures for Orthodontic Services.. A. An orthodontist shall comply with all procedures listed in Regulation .13 of this chapter.. B. The CMS Program shall:. 1) Reimburse for correction of the full permanent dentition; and. 2) Give special consideration to services for children with malocclusions in the mixed dentition associated with cleft palates or other craniofacial deformitiesC. The CMS Program may not reimburse for preliminary visits to the orthodontist..
10.11.03.17.htm 10.11.03.17. 17 Billing Procedures for Durable Goods and Equipment.. A. The durable goods and equipment providers shall comply with all procedures listed in Regulation .13 of this chapter.B. A provider shall charge the CMS Program the usual and customary charge to the general public for similar durable goods and equipment.C. The CMS Program shall:. 1) Pay for covered services which are the least expensive, except for those described in §B of this regulation;2) Determine, based upon
10.11.03.18.htm 10.11.03.18. 18 Billing Procedures for Pharmacy Services.. A. A pharmacy provider shall comply with all procedures listed in Regulation .13 of this chapter.. B. A pharmacy provider shall:. 1) Upon request, produce records to verify any charge to the CMS Program; and. 2) Charge the CMS Program the usual and customary charge to the general public for similar prescriptions.C. Determination of allowable cost for multiple source drugs designated by the Centers for Medicare and Medicaid Services of
10.11.03.19.htm 10.11.03.19. 19 Billing Procedures for Hospitals.. A. All hospitals shall comply with the following procedures:. 1) Hospitals located in Maryland that participate in the CMS Program shall charge and be reimbursed at the Medical Assistance rates approved by the Health Services Cost Review Commission;2) The CMS 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;3) The CMS Program may no
10.11.03.20.htm 10.11.03.20. 20 Cause for Suspension or Removal and Imposition of Sanctions.. A. If the Department determines that a provider, vendor, agent or employee of the provider, vendor, or a person with an ownership interest in the provider or vendor has failed to comply with these regulations, or 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 CMS Program;.
10.11.03.21.htm 10.11.03.21. 21 Funding Availability.. Payment under this chapter is contingent on the availability of funds in accordance with State Finance and Procurement Article, §7-234 and 7-235, Annotated Code of Maryland.
10.11.03.9999.htm 10.11.03.9999. Administrative History Effective date: September 21, 1986 (13:19 Md. R. 2121). Regulations .03, .05, and .12 amended as an emergency provision effective January 1, 1987 (14:2 Md. R. 125) adopted permanently effective March 31, 1987 (14:6 Md. R. 715)Regulation .12 amended effective August 24, 1987 (14:17 Md. R. 1871). Regulations .01―12 repealed effective November 28, 1988 (15:24 Md. R. 2769) ―. Regulations .01―18 adopted effective November 28, 1988 (15:24 Md. R. 2769) ―.
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