COMAR 10.21.15

Chapter 15 Petition for Emergency Evaluation — Payment for Services

This chapter governs the Maryland Department of Health's payment obligations for emergency psychiatric evaluation services rendered as a direct result of a petition for emergency evaluation under Health-General Article §10-628. It specifies which services are payable (emergency room fees, consultant physician examinations, and emergency transportation), billing procedures and documentation requirements, payment rates for hospitals, physicians, and transportation providers, and subrogation rules requiring providers to first seek payment from the evaluee or insurers before billing the Department. Providers must also ensure equal access to care and maintain confidentiality of the emergency evaluee's medical records.

Code of Maryland Regulations

Chapter 15 Petition for Emergency Evaluation — Payment for Services

Administrative History

Effective date: May 9, 1994 (21:9 Md. R. 751)

Authority

Health-General Article, §10-628, Annotated Code of Maryland

.01 Scope.

These regulations govern payment for specific emergency services, as defined in Health-General Article, §10-628, Annotated Code of Maryland, rendered as a direct consequence of a petition for emergency evaluation.

.02 Definitions.

A.
 In this chapter, the following terms have the meanings indicated.

B.
 Terms Defined.

(1)
 “Consultant” means a physician, licensed by the State, who is not a salaried staff member of the emergency facility and who is authorized by the emergency facility to perform an examination of an emergency evaluee.

(2)
 “Department” means the Maryland Department of Health.

(3)
 “Designated emergency facility” means a health care organization currently identified by the Department to perform the functions identified in Health-General Article, §10-624, Annotated Code of Maryland, or this chapter, or both.

(4)
 “Emergency evaluee” means an individual who has been referred to a designated emergency facility on the basis of a petition for emergency evaluation.

(5)
 “Emergency service” means the service rendered as a direct result of the execution of a valid petition.

(6)
 “Emergency vehicle” means:

(a)
 A vehicle operated by a law enforcement officer; or

(b)
 An ambulance regulated according to 
COMAR 14.22.01
 — 14.22.12.

(7)
 “Examination” means a face-to-face diagnostic interview and examination by a consultant physician that includes a medical history, an assessment of mental status, a neurological examination, an assessment of dangerousness, and a written report outlining the consultant physician's findings and conclusions.

(8)
 “Inpatient facility” means an inpatient institution that provides evaluation, care, or treatment for individuals who have mental disorders.

(9)
 “Petition” means a petition for emergency evaluation that is made by an individual who has reason to believe that the emergency evaluee has a mental disorder and that there is danger of the emergency evaluee's doing bodily harm to the petitioner or another individual.

(10)
 “Provider” means an individual, an association, a partnership, an incorporated or unincorporated group, or a hospital that renders health care service to an emergency evaluee.

.03 Conditions for Payment.

The Department shall pay for emergency service only if:

A.
 As determined according to Health-General Article, §16-202, Annotated Code of Maryland, the emergency evaluee cannot pay the charge for the service; and

B.
 The emergency evaluee does not have health insurance, including Medicare or Medical Assistance, that covers the allowable payment for the service.

Cross References

10.21.15.07A(2)

.04 Payable Services.

The Department shall limit services payable under this chapter to the following emergency services:

A.
 The basic emergency room fee in a designated emergency facility;

B.
 The initial examination performed in the emergency room of a designated psychiatric emergency facility by a consultant physician; and

C.
 Transportation for the emergency evaluee in an emergency vehicle:

(1)
 From the site where the emergency evaluee is located to the designated emergency facility; and

(2)
 If staff at the emergency facility complete an application and two certificates for involuntary admission according to the provisions of Health-General Article, §§10-615 — 10-616, Annotated Code of Maryland, from the designated emergency facility to the inpatient facility where the emergency evaluee is referred for admission.

.05 Billing Procedures.

A.
 The provider shall submit the following documents:

(1)
 A request for payment on a form designated by the Department;

(2)
 A bill that specifies the:

(a)
 Name of the emergency evaluee;

(b)
 Date of service; and

(c)
 Description of service;

(3)
 A copy of the current petition for emergency evaluation;

(4)
 If the bill is for an examination by a consultant physician, a copy of the consultant physician's evaluation that is signed by the examining consultant physician;

(5)
 If the bill is for transportation of an emergency evaluee from a designated emergency facility to an inpatient facility, copies of both completed certificates for involuntary admission and the application for involuntary admission; and

(6)
 Any other documentation required by the Department to determine that the conditions of this chapter have been met.

B.
 The provider shall submit the request for payment within 12 months of the date of service.

C.
 The Department may refuse a request for payment if the request is not accompanied by properly completed forms and documents required under 
§A of this regulation
.

.06 Payment Rates.

The Department shall pay:

A.
 Hospitals, at rates approved by the Health Services Cost Review Commission;

B.
 Physicians, the lesser of the:

(1)
 Amount billed; or

(2)
 The Statewide average of prevailing charges for an examination by a physician consultant based on Medicare's 75th percentile as determined according to 42 CFR Sec. 405.504; and

C.
 Transportation providers, if transportation is by:

(1)
 Ambulance, the lesser of the:

(a)
 Amount billed; or

(b)
 The Statewide average of prevailing charges for an ambulance based on Medicare's 75th percentile; or

(2)
 A law enforcement officer in an emergency vehicle:

(a)
 The cost per mile based on the county's established rates for emergency vehicles; and

(b)
 The cost of the law enforcement officer's hourly wage for the number of hours, not to exceed 4 hours, required to transport the emergency evaluee.

.07 Subrogation by the Department.

A.
 Before billing the Department, the provider shall:

(1)
 Take all reasonable steps to collect the charge from the emergency evaluee and, if applicable, from insurers, including Medicare and Medical Assistance; or

(2)
 Make and document a determination of the evaluee's inability to pay, according to the provisions of 
Regulation .03 of this chapter
.

B.
 A provider:

(1)
 Shall accept as payment in full the maximum payment amount allowable under Medicare for services rendered to eligible participants; and

(2)
 May not bill the Department for any amount in excess of that allowable under 
§B(1) of this regulation
.

C.
 If a provider receives payment from both the Department and another source, within 30 calendar days of receipt of payment by the other source, the provider shall refund to the Department the amount in excess of the maximum payment allowable under the provisions of 
§B of this regulation
 that was paid by the Department.

D.
 The provider shall immediately reimburse the Department for any overpayment.

.08 Patients' Rights.

A.
 Access to Care. Providers of emergency services shall give an emergency evaluee equal access to treatment and services that are available or medically indicated, regardless of diagnosis, handicap status, race, age, sex, national origin, religious or political opinions or affiliations, or sources of payment for care.

B.
 Providers of emergency services shall recognize and respect an emergency evaluee's dignity in the provision of care and treatment.

C.
 Confidentiality.

(1)
 The emergency evaluee's medical record is governed by the provisions of confidentiality as set forth in Health-General Article, Title 4, Subtitle 3, and §19-308.2, Annotated Code of Maryland.

(2)
 The right of confidentiality does not preclude routine audit or payment processes.