COMAR 10.09.95

Chapter 95 Special Psychiatric Hospitals

This chapter establishes Maryland Medicaid (Medical Assistance Program) participation requirements, covered services, utilization review, and reimbursement/cost-settlement procedures for special psychiatric hospitals (inpatient psychiatric facilities). Operators must obtain licensure as a specialty psychiatric hospital, meet staffing and documentation standards, obtain preauthorization for elective admissions, and submit annual cost reports. The chapter also covers partial hospitalization services when separately approved, and sets out payment rates, administrative day billing rules, and appeal procedures for cost settlements.

Code of Maryland Regulations

Chapter 95 Special Psychiatric Hospitals

Administrative History

Effective date: April 10, 2017 (44:7 Md. R. 354)

Regulation .05B
 amended effective September 9, 2019 (46:18 Md. R. 774); May 1, 2023 (50:8 Md. R. 338)

Regulation .07A
 amended effective December 31, 2018 (45:26 Md. R. 1245)

Authority

Health-General Article, §§2-104(b), 15-102.8, 15-103, and 15-105, Annotated Code of Maryland

.01 Definitions.

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

B.
 Terms Defined.

(1)
 “Administrative day” means a day of medical services delivered to a participant who no longer requires the level of care which the provider is licensed to deliver and is awaiting placement in a nursing home or residential care facility.

(2)
 “Admission” means the formal acceptance by a specialty psychiatric hospital of a patient who is to be provided with room, board, and medically necessary services in an area of the hospital where patients stay at least overnight.

(3)
 “Ancillary services” means diagnostic and therapeutic services, provided exclusive of room and board, including but not limited to:

(a)
 Radiology;

(b)
 Laboratory tests;

(c)
 Pharmacy services; and

(d)
 Physical therapy services.

(4)
 “Appropriate facility” means:

(a)
 A facility located within a 25-mile radius of the participant’s residence; or

(b)
 If acceptable to the participant, a more distant facility, which is licensed and certified to render the participant’s required level of care, except when the only facility or facilities that provide the level of care and specialized services required by the participant exceed that distance.

(5)
 “Concurrent review” means a periodic reauthorization of continued eligibility for the level of services provided by a special psychiatric hospital which allows for close monitoring of the participant’s progress, treatment goals, and objectives during an inpatient hospitalization.

(6)
 “Date of service” means:

(a)
 For inpatient hospitalizations, the date of admission into a special psychiatric hospital up to, but not including, the date of discharge;

(b)
 For outpatient services, the date services are rendered in the outpatient department of the special psychiatric hospital; and

(c)
 For observation services, the date or dates the services are rendered in a special psychiatric hospital, which are ordered by a medical staff practitioner to determine the need for inpatient admission.

(7)
 “Department” means the State Maryland Department of Health, which is the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

(8)
 “Designee” means any entity designated to act on behalf of the Department.

(9)
 “Electronic signature” means a secure electronic identification of an individual who authorizes an electronic record or transaction.

(10)
 “Emergent condition” means a disease, illness, or injury characterized by sudden onset and symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in:

(a)
 Placing the participant’s health or, with respect to a pregnant woman, the health of the woman or unborn child in serious jeopardy;

(b)
 Serious impairment of bodily functions; or

(c)
 Serious dysfunction of any bodily organ or part.

(11)
 “Health Services Cost Review Commission (HSCRC)” means the independent organization within the Maryland Department of Health which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.

(12)
 “Level of care” means an assessment that an individual needs the level of services provided in a special psychiatric hospital.

(13)
 “Maryland Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.

(14)
 “Medicaid” means the Maryland Medical Assistance Program.

(15)
 “Medically necessary” means that the service or benefit is:

(a)
 Directly related to diagnostic, preventative, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;

(b)
 Consistent with standards of good medical practice;

(c)
 The most cost-efficient service that can be provided without sacrificing effectiveness or access to care; and

(d)
 Not primarily for the convenience of the participant, family, or provider.

(16)
 “Medicare” means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.

(17)
 “Mental health services” means those services described in 
COMAR 10.09.59.06
 rendered to treat the diagnoses set forth in COMAR 10.09.70.02.

(18)
 “Nonqualified alien” means a foreign-born resident who:

(a)
 Is not a naturalized U.S. citizen; and

(b)
 Is eligible for federal Medical Assistance coverage of only emergency medical services, as specified under 
COMAR 10.09.24.05
-2A.

(19)
 “Observation services” means the medically necessary diagnostic services used to assess the participant’s outpatient condition to determine the need for possible admission to an inpatient special psychiatric care setting.

(20)
 “Organ” means a part of an organism that is typically self-contained and has a specific vital function, such as a heart or liver.

(21)
 “Out-of-State hospital” means any hospital outside of Maryland, except for hospitals located in the District of Columbia.

(22)
 “Outpatient services” means services provided to the participant on the hospital campus that do not require hospital admission.

(23)
 “Partial hospitalization” means outpatient, intensive, nonresidential psychiatric treatment, which is an alternative to inpatient acute general hospitalization, for any part of a 24-hour day for a minimum of 4 consecutive hours per day.

(24)
 “Participant” means a person who is certified as eligible for and is receiving Medical Assistance benefits.

(25)
 “Patient” means an individual awaiting or undergoing health care or treatment.

(26)
 “Plan of treatment” means a written plan, developed to address the referred problem or problems, which includes:

(a)
 Diagnosis;

(b)
 Treatment goals;

(c)
 Frequency of visits for each type of service ordered;

(d)
 Duration of treatment of each type of service ordered;

(e)
 Prognosis; and

(f)
 Other appropriate items.

(27)
 “Preauthorization” means the approval required from the Department or its designee before a service can be rendered by the provider and reimbursed.

(28)
 “Program” means the Maryland Medical Assistance Program.

(29)
 “Provider” means a special psychiatric hospital which through agreement with the Department has been identified as a Program provider by the issuance of a provider number.

(30)
 “Retrospective review” means the process of determining medical necessity of an inpatient admission after the participant has been discharged from the hospital.

(31)
 “Special psychiatric hospital” means an institution that:

(a)
 Provides short-term services for psychiatric illnesses in a hospital setting with facilities, medical staff, and all necessary personnel to provide diagnosis, care, and treatment;

(b)
 Falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland; and

(c)
 Is licensed pursuant to 
COMAR 10.07.01
 or other applicable standards established by the state in which the service is provided.

Cross References

10.09.95.03B(7)(b)

.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 specialty psychiatric hospital; and

(2)
 Obtain other licenses, as set forth in 
COMAR 10.07.01
.

B.
 A provider shall ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services performed, and:

(1)
 If located in Maryland, comply with requirements of:

(a)
 Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland; and

(b)
 
COMAR 10.10.01
; or

(2)
 If located out-of-State, comply with other applicable standards established by the state or locality in which the service is provided and with the requirements of 
COMAR 10.09.09.02
.

.03 Conditions for Participation.

A.
 A provider shall meet all conditions for participation as set forth in 
COMAR 10.09.36.03
.

B.
 To participate in the Program as a special psychiatric 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 Department of Health and Human Services;

(2)
 Meet the following staffing requirements 24 hours per day, 7 days per week:

(a)
 On-call or on-site physician services including psychiatric physicians;

(b)
 On-site registered nurses;

(c)
 On-site advanced cardiac life support services;

(3)
 If licensed to provide inpatient psychiatric services for individuals younger than 21 years old:

(a)
 Meet the requirements for participation as defined in 42 CFR §440.160; and

(b)
 Provide acute psychiatric services as defined in 42 CFR Part 441, Subpart D;

(4)
 Directly provide or make available through contractual arrangements or transfer agreements, medically necessary covered services;

(5)
 Accept payment by the Program as payment in full for the covered service;

(6)
 Make available to the Department or its designee the participant’s medical record for review and certification of medical necessity for admission and continuation of stay;

(7)
 Maintain documentation of each contact with the participant as part of the medical record, which, at a minimum, includes:

(a)
 Date of service;

(b)
 A plan of treatment as defined in 
Regulation .01B of this chapter
;

(c)
 The participant’s chief medical complaint or reason for visit;

(d)
 A description of the services provided, including:

(i)
 Progress notes;

(ii)
 Imaging studies;

(iii)
 Laboratory results;

(iv)
 Medication administration records; and

(v)
 Discharge summary; and

(e)
 A signature, electronic or handwritten, along with the printed or typed name of the individual providing care, with the appropriate title;

(8)
 Submit to the Department or its designee within 5 months of the close of the hospital’s fiscal year, as required by the Department, a hospital cost report for outpatient services which are subject to cost settlement in accordance with 
Regulation .11 of this chapter
;

C.
 If an out-of-State or District of Columbia hospital, the special psychiatric hospital shall:

(1)
 Unless a waiver has been granted by the Secretary of Health and Human Services, have in effect a utilization review plan applicable to all participants who receive Medical Assistance under Title XVII of the Social Security Act which meets the requirements of §1861(k) of the Social Security Act; and

(2)
 Comply with applicable regulations of this chapter and 
COMAR 10.09.36
.

.04 Covered Services.

A.
 The Program covers the following inpatient special psychiatric hospital services:

(1)
 Medically necessary services for the number of days, per admission, including days certified by the Department or its designee;

(2)
 Medically necessary mental health services authorized in accordance with 
COMAR 10.09.59.08
 and as set forth in 
Regulation .05B(4) of this chapter
;

(3)
 Medically necessary services when these services are:

(a)
 Necessary for the provision of diagnostic, curative, palliative, or rehabilitative treatment; and

(b)
 Described in the participant’s medical record in sufficient detail to support the invoices submitted for services.

(4)
 Administrative days for the length of time certified by the Department or its designee;

(5)
 Leaves of absence for therapeutic reasons or extenuating circumstances up to 12 hours per day, if the participant returns the same day, before the census check; and

(6)
 Observation services.

B.
 The Program covers partial hospitalization when the hospital has:

(1)
 Written approval from the Office of Licensing and Certification Programs to be a provider of partial hospitalization in accordance with 
COMAR 10.21.02
;

(2)
 A certificate of need from the Maryland Health Resources Planning Commission, if required, to be a provider of partial hospitalization; and

(3)
 Obtained preauthorization in accordance with 
COMAR 10.09.59.08
.

.05 Limitations.

A.
 There are limitations placed on the coverage of some special psychiatric hospital inpatient and outpatient services.

B.
 The Program does not cover:

(1)
 Special psychiatric hospital services, procedures, drugs or admissions that are investigational or experimental;

(2)
 Services identified by the Department or its designee as not medically necessary;

(3)
 Elective inpatient admissions without preauthorization;

(4)
 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;

(5)
 Inpatient mental health services for an individual between 21 and 64 in a special psychiatric hospital of more than 16 beds that primarily engages in providing mental health services for an individual who is not waiver-eligible, as defined in 
COMAR 10.67.01.01
, except:

(a)
 When receiving mental health services in the special psychiatric hospital immediately before the participant reached 21 years old, in which case the services may be continued until the earlier of the following:

(i)
 The date the participant no longer requires the services; or

(ii)
 The date the participant reaches 22 years old;

(b)
 Effective July 1, 2019, services of up to 15 days per month, when:

(i)
 The participant has co-occurring substance use and mental health diagnoses; and

(ii)
 The provider is located in-State or, effective January 1, 2022, the provider is located in a contiguous state or the District of Columbia; or

(c)
 Effective January 1, 2022, services up to 60 days, when:

(i)
 The participant has a primary mental health diagnosis; and

(ii)
 The provider is located in-State, a contiguous state, or the District of Columbia;

(6)
 Outpatient visits for one or more of the following:

(a)
 Prescription drug or food supplement pick up;

(b)
 Collection of specimens for laboratory procedures;

(c)
 Recording of an electrocardiogram;

(d)
 Ascertaining the participant’s weight; and

(e)
 Administration of vaccines;

(7)
 Leaves of absence beyond the period of the census check of the same day;

(8)
 Psychological evaluations and treatments except when:

(a)
 Ordered by a physician, and the medical necessity is documented in the participant’s medical record; or

(b)
 Performed as mental health services as part of an approved treatment plan;

(9)
 Telephones, televisions, or personal comfort items or services;

(10)
 Duplicated care or service as indicated by more than one charge for the same stay or more than one room accommodation for the same time, for example, a charge for an inpatient day and observation room charge;

(11)
 Administrative days for participants pending discharge to home or nonmedical institutions;

(12)
 Inpatient and outpatient diagnostic and laboratory services not ordered by the attending physician or other practitioner;

(13)
 Inpatient days provided in excess of the days approved by the Department or its designee;

(14)
 Hospital laboratory tests which are coverable under 
COMAR 10.09.09
, unless the specimen is obtained in the hospital;

(15)
 Admissions to special psychiatric hospitals, unless the participant is diagnosed with any one of the specialty mental health codes listed in COMAR 10.09.70.02 or unless the Department or its designee grants a special exception based on the complexity of the situation at admission; or

(16)
 Elective admissions to hospitals outside of Maryland, except the District of Columbia, unless the Department or its designee determines that comparable services are not available in Maryland.

Cross References

10.09.95.04A(2)

.06 Utilization Review Requirements.

A.
 Elective Inpatient Preauthorization Reviews.

(1)
 The special psychiatric hospital shall only request preauthorization for inpatient stays when such services:

(a)
 Cannot be provided on an outpatient basis; or

(b)
 Can only be provided in a facility that is licensed as a special psychiatric hospital.

(2)
 The special psychiatric hospital shall obtain preauthorization for elective inpatient admissions from the Department or its designee, before the participant is admitted, by providing the following information including, but not limited to:

(a)
 Participant’s medical history and physical; and

(b)
 Sufficient clinical information or documentation that supports the medical necessity of the inpatient admission.

B.
 Concurrent Review Process.

(1)
 The concurrent review process shall be initiated by the hospital.

(2)
 If the participant remains hospitalized, additional days shall be certified by the Department or its designee before the termination of the previously certified days.

(3)
 The special psychiatric hospital shall forward sufficient clinical information or documentation to the Department or its designee that supports the need for continuing care. Information submitted shall include:

(a)
 Current health status;

(b)
 Treatment received to date;

(c)
 Proposed treatment plan for continued stay; and

(d)
 Discharge planning.

C.
 Retrospective Reviews.

(1)
 The special psychiatric hospital shall request that the Department or its designee perform a retrospective review of an inpatient admission after the participant is discharged, to determine the medical necessity of the admission.

(2)
 The special psychiatric hospital shall provide the following to the Department or its designee when requesting a retrospective review following discharge from a special psychiatric hospital. Documentation submitted shall include, but is not limited to:

(a)
 The participant’s complete medical record;

(b)
 The principal, secondary, and tertiary diagnoses; and

(c)
 All relevant procedure codes.

D.
 Reviews for Nonqualified Aliens. The Department or its designee reviews the admission and discharge summary of an emergency inpatient admission for a nonqualified alien to determine whether the inpatient special psychiatric hospital stay meets the emergent condition criteria as defined in 
COMAR 10.09.24.05
-2A.

.07 Payment Procedures.

A.
 Reimbursement Principles.

(1)
 The Department will make no direct reimbursement to any State-operated hospital. The Department will claim federal fund recoveries from the U.S. Department of Health and Human Services for services to participants in State-operated hospitals.

(2)
 The Department shall compare the current rates with the projected upper payment limit for inpatient days of service on or after July 1, 2012, in freestanding private psychiatric hospitals in Maryland whose rates for commercial providers are set by the HSCRC.

(3)
 If the rates do not exceed the projected upper payment limit calculated by the Department, the Department shall reimburse these hospitals using a rate of 94 percent of the current rates for services set by the HSCRC for each hospital’s commercial providers in the fiscal year the prospective payments are made.

(4)
 If the rates do exceed the projected upper payment limit calculated by the Department, the per diem payments to each such hospital shall be decreased by the same proportion that the projected upper payment limit is exceeded.

(5)
 If the Program discontinues using rates which have been approved by HSCRC, the Program shall reimburse providers:

(a)
 According to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413; or

(b)
 On the basis of charges if less than reasonable cost.

(6)
 The Department may not reimburse for the services of a hospital’s salaried or contractual physicians as a separate line item. When HSCRC has included these salaries in the hospital’s costs, charges for these services shall be included in the room and board rate or the appropriate ancillary service only.

(7)
 Payment advances other than those made in accordance with HSCRC regulations may not be made routinely.

(8)
 Inpatient and outpatient services in District of Columbia special psychiatric and outpatient services in in-State special psychiatric hospitals are cost-settled on an annual basis according to 
§B of this regulation
.

(9)
 Effective October 1, 2018, an out-of-State special psychiatric hospital shall be reimbursed the lesser of its charges or the amount reimbursable by the host state’s Title XIX agency.

(10)
 An out-of-State provider shall submit proof of host state rates on an annual basis.

B.
 Retrospective Cost Reimbursement.

(1)
 Except as specified in 
§A of this regulation
, a special psychiatric hospital not approved by the Program for reimbursement according to HSCRC rates shall be reimbursed:

(a)
 According to Medicare standards and principles for retrospective cost reimbursement described in 42 CFR §413; or

(b)
 On the basis of charges, if less than reasonable cost.

(2)
 In calculating retrospective cost reimbursement rates, the Department or its designee will deduct from the designated costs or group of costs those restricted contributions which are designated by the donor for paying certain provider operating costs, groups of costs, or costs of specific groups of participants. When the cost, or group or groups of costs designated, cover services rendered to all participants, including Medical Assistance participants, operating costs applicable to all participants shall be reduced by the amount of the restricted grants, gifts, or income from endowments thus resulting in a reduction of allowable costs.

(3)
 Final settlement for services in the provider’s fiscal year shall be determined based on Medicare retrospective cost principles found at 42 CFR §413, adjusted for Medicaid allowable costs. Allowable costs specific to the Program shall be limited to a base-year cost per discharge increased by the applicable federal rate of increase times the number of Program discharges for that fiscal year.

(4)
 Base Year. For purposes of determining limits on the increase of cost, in accordance with Medicare regulations, the base year shall be:

(a)
 For an existing provider, the first year of entering into the Program or the first year separate rates for the unit or units of service or services are approved; and

(b)
 For a new provider, or all of these, the 12-month period immediately before the provider was initially subjected to target rate increases.

(5)
 Initial Interim Rates. In order to establish an initial interim rate, the provider shall submit to the Department or its designee, before the beginning of the first billing period, at least 90 days before the beginning of billing for services, the following:

(a)
 A detailed cost build-up, consistent with Medicare principles and cost finding, that supports the requested rate;

(b)
 A current, projected, and prior year’s charge rate schedule;

(c)
 Finalized prior year’s Medicare cost reports and the most current submission;

(d)
 A detailed revenue schedule; and

(e)
 Audited financial statements.

(6)
 The provider shall supply the Department or its designee the assurances necessary to establish that its customary charges to participants liable for payment on a charge basis exceed the allowable cost for these services.

(7)
 Initial Interim Rates for Newly Established Services or Providers.

(a)
 The provider shall submit to the Department or its designee, a detailed cost build-up, consistent with Medicare principles and cost finding, that supports the requested rate that follows Medicare principles and cost finding.

(b)
 The Department will compare the rate with a compatible facility and determine a reasonable rate that does not exceed the projected charges.

(8)
 Revision of Interim Rates.

(a)
 The provider may request an interim rate revision should the actual and projected cost exceed the interim rate by 10 percent.

(b)
 The provider shall furnish the Department or its designee with appropriate schedules showing the reason for the increase and other any other information that supports the rate increase.

(c)
 The Department will lower the provider’s interim rate to approximate the final allowable reasonable cost based on the results of the prior year’s review.

(d)
 The provider may request not more than two interim rate revisions during the accounting year.

(9)
 Cost Settlement.

(a)
 The provider shall submit to the Department or its designee:

(i)
 A Medicaid cost report based on actual data using the cost reporting forms used by Medicare for retrospective cost reimbursement;

(ii)
 A copy of the provider’s Program log; and

(iii)
 A finalized Medicare cost report for the cost reporting year.

(b)
 The final Program cost report shall be sufficiently detailed to support a separate cost finding for Maryland Medical Assistance unique cost centers. The provider shall also submit a copy of its Maryland Medical Assistance log. The submitted cost report shall be in sufficient detail to support a separate cost finding for designated Maryland Medical Assistance unique cost centers.

(c)
 Tentative cost settlements may not be performed on a routine basis. However, the Program may, when it determines appropriate, calculate tentative settlements. The provider shall furnish the Department or its designee with a finalized Medicare cost report for the cost reporting year.

(d)
 The Department will base final settlement on the results of the finalized Medicare cost reports.

C.
 The Program shall reimburse room and board charges for the day of admission, but may not reimburse room and board charges for the day of discharge from the hospital.

D.
 The provider shall submit request for payment according to procedures established by the Department.

E.
 Payments on Medicare claims are authorized if:

(1)
 The provider accepts Medicare assignment;

(2)
 Medicare makes direct payment to the provider;

(3)
 Medicare determined the services were medically necessary;

(4)
 The services are covered by the Program; and

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

F.
 Payment on Medicare claims is subject to the following provisions:

(1)
 Deductible and co-insurance, according to the limits of 
§E of this regulation
, shall be paid subject to the HSCRC discounts, except in the case of a participant receiving hospital services in an out-of-State facility, in which case deductible and co-insurance shall be paid in full; or

(2)
 Services not covered by Medicare, but by the Program, if medically justified according to 
§E of this regulation
.

G.
 Administrative Days.

(1)
 To be paid for administrative days, the special psychiatric hospital shall document, on forms designated by the Department, information demonstrating that the participant who was initially eligible has been determined to no longer require special psychiatric hospital services and the provider has:

(a)
 Received a determination from the Department or its designee that the participant requires the level of service provided in a lower-acuity facility, but an appropriate facility is not available;

(b)
 Established a plan for discharge during the period of administrative days, is actively pursuing placement at an appropriate level of care for the participant, and has documented this activity in the participant’s record;

(c)
 Maintained documentation in the participant’s medical record that placement activity was conducted no fewer than 3 days per week during the period for which payment is requested for administrative days; and

(d)
 Notified the local agency responsible for development of the discharge treatment and education plan of the potential placement, if the participant is at risk of a residential treatment center placement on admission;

(2)
 If the participant requires the level of care provided by a residential treatment center and a bed in a residential treatment center is not available, in order to be paid for administrative days, the special psychiatric hospital shall document that it timely notified local coordinating councils and any other local agency, as appropriate, of the necessity to continue inpatient psychiatric service at a residential treatment center before the termination of the need for inpatient psychiatric hospitalization;

(3)
 If the participant is at an inappropriate level of care but cannot be moved, in order to be paid for administrative days, the special psychiatric hospital shall:

(a)
 Provide the attending physician’s declaration that, because of physical or emotional problems, the participant is unable to be moved;

(b)
 Document in the participant’s medical record the attending physician’s reasons why the participant cannot be moved; and

(c)
 Document the attending physician’s reevaluation of the participant’s inability to be moved in the participant’s record at least every 14 days in special psychiatric hospital.

H.
 Payment for approved administrative days for a special psychiatric hospital seeking placement of a participant to a residential treatment center shall be the average residential treatment center rate issued pursuant to 
COMAR 10.09.29.13B
.

I.
 The Department may not reimburse a special psychiatric hospital for administrative days if:

(1)
 The special psychiatric hospital bills the Program for days of care for which the hospital is licensed to provide; or

(2)
 The Program or the Program’s designee determines the participant no longer requires the level of care for the days requested.

J.
 The Department may not make direct payment to the participant.

K.
 Billing time limitations for claims submitted pursuant to this chapter are set forth in 
COMAR 10.09.36.06
.

L.
 The Department reserves the right to return to the provider, before payment, all invoices not properly completed.

M.
 Noncompliance with the Program’s requirements as determined by the Department or its designee shall result in nonpayment of the claim.

Cross References

10.09.95.12A

10.09.95.12C

.08 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.

.09 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
.

Cross References

10.09.95.11E

10.09.95.12J

.10 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
.

.11 Submitting Cost Reports.

A.
 The provider shall submit to the Department or its designee, in the form prescribed, financial and statistical data within 5 months after the end of the provider’s fiscal year unless the Department grants the provider an extension or the provider discontinues participation in the Program.

B.
 For hospitals who do not submit reports within 5 months, for whom an extension has not been granted, and who are reimbursed according to Medicare standards and principles for retrospective cost reimbursement as described in 42 CFR §413, the Department shall:

(1)
 Withhold from the provider a maximum of 5 percent of the current monthly interim payment starting the calendar month after the calendar month in which the report is due and any subsequent calendar months until the report has been submitted; and

(2)
 Refund withholdings at cost settlement.

C.
 If a provider discontinues participation, financial and statistical data shall be submitted to the Department within 45 days after the effective date of termination.

D.
 The Program shall grant an extension for submission of cost reports:

(1)
 Upon written request by the provider, setting forth the specific reasons for the request, if the Department determines, taking into consideration the totality of the circumstances, that the request is reasonable; or

(2)
 Concurrent with any extension granted to the special psychiatric hospital by Medicare, but not to exceed 60 days from the due date of cost reports.

E.
 In addition to a reduction in payment percentage or withholding a percentage of interim payment pursuant to 
§B of this regulation
, when a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year and the provider has not received an extension, the Department may impose one or more sanctions as provided for in 
Regulation .09 of this chapter
.

F.
 When a report is not submitted by the last day of the 6th month after the end of the provider’s fiscal year or a report is submitted but the provider cannot furnish proper documentation to verify costs, the Department shall, if applicable, make final cost settlement for that fiscal year at a certain percentage of the last final per diem rates for which the Department has verified costs for that facility, provided that the rates established will not exceed the maximum per diem rates in effect when the facility’s costs were last settled.

G.
 For purposes of §§A—F of this regulation, reports are considered received when the submitted reports are completed according to instructions issued by the Department or its designee.

Cross References

10.09.95.03B(8)

.12 Cost Settlement.

A.
 The Department or its designee shall notify each provider participating in the Program of the results of the final settlement under 
Regulation .07 of this chapter
.

B.
 Within 60 days after the provider receives the notification described in 
§A of this regulation
, the Department shall pay the amount due to the provider regardless of whether the provider files an appeal.

C.
 The provider may request review of the settlement under 
Regulation .07 of this chapter
 by filing written notice with the Program’s Appeal Board within 30 days after receipt of the notification of the results of the settlement from the Department or its designee.

D.
 The Appeal Board shall be composed of the following:

(1)
 A representative of the hospital industry who is:

(a)
 Knowledgeable in Medicare and Medicaid reimbursement principles; and

(b)
 Appointed by the Secretary of the Department;

(2)
 An individual who:

(a)
 Is employed by the State;

(b)
 Is knowledgeable in Medicare and Medicaid reimbursement principles;

(c)
 Did not participate in the verification of costs; and

(d)
 Is appointed by the Secretary of the Department; and

(3)
 A third member selected by the first two members of the Appeal Board.

E.
 When the Appeal Board reviews an appeal from a provider in which an Appeal Board member is employed or in which the member has a financial or personal interest, the Secretary of the Department shall designate an alternate for the member.

F.
 If the provider elects not to appeal to the Appeal Board, the provider shall:

(1)
 Pay the amount due within 60 days after the notification described in 
§A of this regulation
; or

(2)
 Request a longer payment schedule within 60 days after the provider receives notification of the amount due to the Program.

G.
 After consultation with the provider, the Department may establish a longer payment schedule if it determines, based on sufficient documentation submitted by the provider, that failure to grant a longer payment schedule would:

(1)
 Result in financial hardship to the provider; or

(2)
 Have an adverse effect on the quality of participant care furnished by the facility.

H.
 If the provider elects to appeal to the Appeal Board, the following provisions apply:

(1)
 Within 30 days after the filing of an appeal by a provider that the Department or its designee determined owes money to the Program, the Department or its designee shall:

(a)
 Recalculate the amount due to the Program based on the verification, exclusive of the amount in controversy which is subject to the appeal; and

(b)
 Notify the provider of that amount;

(2)
 In order to enable the Department or its designee to perform this recalculation, the provider shall indicate the specific adjustment and the specific amount being appealed;

(3)
 Subject to the provisions of 
§H(4) of this regulation
, payment for the amount due the Program, if any, after the recalculation, shall be made within 60 days after the provider receives notification of the recalculation; and

(4)
 If a provider requests a longer payment schedule within 60 days after the provider receives notification of the recalculation, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with 
§G of this regulation
.

I.
 Appeal Board Findings.

(1)
 After the Department receives the findings of the Appeal Board, the Department shall:

(a)
 Determine the amount that is due either to the Program or to the provider; and

(b)
 Notify the provider of that amount.

(2)
 The portion of the amount in controversy that is paid is subject to an award of interest that is:

(a)
 Calculated from the date the appeal was filed through the date of payment; and

(b)
 Based on the 6-month Treasury Bill rate in effect on the date the appeal was filed.

(3)
 Interest paid to a provider under 
§I(2) of this regulation
 is not subject to any offset or other reduction against otherwise allowable costs.

(4)
 If the provider accepted the determination made under 
§I(1) of this regulation
, within 60 days after the provider receives the notification under 
§I(1) of this regulation
, the Program shall pay the amount the Department determined is due the provider, if any.

(5)
 Subject to 
§I(6) of this regulation
, within 60 days after the provider receives the notification, the provider shall pay the amount due the Program, if any.

(6)
 If a provider requests a longer payment schedule within 30 days after the provider receives notification of the amount due the Program, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with 
§G of this regulation
.

J.
 After expiration of the 60-day payment period, or longer payment schedule established by the Department as described in §§F—I of this regulation, and in addition to the sanctions provided in 
Regulation .09 of this chapter
, the Department may recover the unpaid balance by withholding the amount due from the interim payment which would otherwise be payable to the provider.

K.
 The Department or a provider aggrieved by a reimbursement decision of the Appeal Board may appeal the Appeal Board’s decision as the final agency decision under the Administrative Procedure Act, 
State Government Article, §10-222, Annotated Code of Maryland
.

L.
 If the provider or the Department appeals a final decision of the Appeal Board, the provider or the Department shall place any money due from the provider or from the Program in an interest-bearing escrow account. The money due shall include the interest, based on the rate in 
§I(2)(b) of this regulation
, calculated from the date of the administrative appeal through the date of opening the escrow account. The money shall remain in escrow until a final decision has been rendered. Upon a final determination of the dispute, the appropriate person administering the escrow account shall distribute the money in that account, including any interest accrued, in conformity with the final determination.

M.
 The provider may file an appeal of the results of the settlement with the Medicare Appeal Board as a substitute for the Department’s Appeal Board, and the decision rendered by the Medicare Appeal Board will be accepted by the Department as binding.

Cross References

10.01.09.01

10.01.09.06A

.13 Interpretive Regulation.

General policies governing the interpretive regulations applicable to all providers are set forth in 
COMAR 10.09.36.10
.