10.09.68.03

.03 Conditions for Reimbursement for Self-Referred Services.

A. A school-based health center, designated by the Department as meeting the criteria specified in Regulation .01 of this chapter, is eligible for reimbursement by the student's MCO for the following self-referred services:

(1) Comprehensive well-child care when performed by EPSDT certified providers and rendered according to EPSDT standards;

(2) Follow-up of positive or abnormal EPSDT screening components without approval of the PCP except when referral for specialty care is indicated;

(3) Diagnosis and treatment of illness and injury that can be effectively managed in a primary care setting; and

(4) Family planning services specified in COMAR 10.09.65.20A(2).

B. An MCO is not required to reimburse a school-based health center for providing:

(1) Basic school health services as defined in COMAR 13A.05.05.05—.15;

(2) Services to nonstudents;

(3) Nursing or other health services provided as part of an enrollee's IEP or IFSP;

(4) Skilled nursing services provided to enable an enrollee to be safely maintained in the school setting such as:

(a) Gastroesophaegeal tube (GT) feedings;

(b) Catheterization;

(c) Oral, nasotracheal, or tracheal suctioning; and

(d) Nebulizer treatments;

(5) School health services which are required in all school settings such as:

(a) Routine assessment of minor injuries;

(b) First aid;

(c) Administration of medications including supervision of self-administered medications;

(d) General health promotion counseling; or

(e) Review of health records;

(6) Mandated health screening services performed at specific intervals in all public schools such as:

(a) Hearing;

(b) Vision; and

(c) Scoliosis screenings;

(7) Routine sports physicals;

(8) Vaccines supplied by the VFC;

(9) Visits for the sole purpose of:

(a) Administering vaccines;

(b) Administering medication;

(c) Checking blood pressure;

(d) Measuring weight;

(e) Interpreting lab results; or

(f) Group or individual health education;

(10) Services provided outside of the physical location of the approved SBHC;

(11) Services not covered by MCOs such as dental and specialty mental health; or

(12) Services provided without prior authorization when prior authorization is required by the MCO.

C. The school-based health center providing self-referred services shall:

(1) Verify eligibility and MCO assignment through EVS on the day of service;

(2) Submit claims within 180 days of performing the service;

(3) Submit claims using the CMS 1500 for paper processing and the HIPAA compliant 837P for electronic processing;

(4) Bill third party insurers before billing the MCO with the exception of well-child care and immunizations; and

(5) Transmit a health visit report, as designated by the Department, to the student's MCO and PCP within 3 business days, for inclusion in the student-enrollee's medical record and if follow-up care with the PCP is required within 1 week and the health visit report is mailed, the school-based health center shall also telephone, email, or fax the health visit report to the student's MCO and PCP on the day of the SBHC visit.

D. An MCO shall provide school-based health centers in its service area with the current information needed to facilitate communication between the SBHC, PCP, and the MCO regarding care provided to the MCO's enrollees, and to effect reimbursement by the MCO, including:

(1) Information concerning the MCO's policies and procedures regarding provision of pharmacy and laboratory services; and

(2) Contact information, including a listing of:

(a) The name and number of an MCO representative who serves as the SBHC's contact person for coordination of care;

(b) The address for submitting claims and encounter information; and

(c) Information on how to identify and contact the student-enrollee's PCP.

E. The SBHC, MCO, and PCP shall use telephone, fax, mail, and email to communicate.

F. An MCO shall pay undisputed claims of the SBHC for services provided to its enrollees within 30 days of the MCO's receipt of the invoice.