10.09.22.06

.06 Payment Procedures.

A. Reimbursement Principles.

(1) Reimbursement by the Program is for services described in Regulation .04B of this chapter provided at a free-standing dialysis facility which has been approved for Medicare by the Division of Survey and Certification of CMS.

(2) Reimbursement shall be consistent with the rates established by the Program for those services which are approved by Medicare.

(3) Physician services are not reimbursed under this regulation. Reimbursement for physician services are in accordance with COMAR 10.09.02.07.

B. The provider shall submit a request for payment on the form designated by the Department.

C. The Program reserves the right to return to the provider, any invoice that is not properly completed.

D. A provider shall bill the program the established Medicaid rate for dialysis services.

E. Payments on Medicare claims are authorized if:

(1) The provider accepts Medicare assignment;

(2) Medicare makes direct payment to the provider;

(3) Medicare has determined that the services are medically necessary;

(4) Services are covered by the program; and

(5) Initial billing is made directly to Medicare according to Medicare guidelines.

F. The Department will make supplemental payment on Medicare claims subject to the following provisions:

(1) Deductible and coinsurance are to be paid in full; and

(2) Services not covered by Medicare are payable according to §D of this regulation.

G. The provider may not bill the Program for:

(1) Completion of forms and reports;

(2) Broken or missed appointments;

(3) Professional services rendered by mail or telephone; or

(4) Home visits unless satisfactorily documented as an emergency.

H. The Program will make no direct payment to a participant.

I. The Program will make no separate direct payment to any person employed by or under contract to any free-standing dialysis facility for services covered under this regulation.

J. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.