Md. Code Regs. 10.09.08.06

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.08.06 - Limitations

The Program does not cover the following:

A. Services not specified in Regulation .04 of this chapter;

B. Services not medically necessary;

C. Investigational and experimental drugs and procedures;

D. Procedures solely for cosmetic purposes;

E. Services denied by Medicare as not medically justified;

F. Freestanding clinic services for inpatient participants in State-operated facilities serving individuals with intellectual disabilities;

G. Freestanding clinic services provided to hospital inpatients;

H. Freestanding clinic visits when patients are referred to hospital outpatient departments or emergency rooms for services ordinarily provided in freestanding clinics covered by this chapter;

I. Freestanding clinic visits solely for the purpose of one or more of the following:

(1) Prescription drugs or collection of laboratory specimens, unless otherwise allowed;

(2) Certification or recertification of food supplements;

(3) Performing laboratory tests required only for certification or recertification of food supplement programs;

(4) Nutritional assessments in the absence of diagnosis of nutritional disorders, unless EPSDT or primary health services are provided at the same time;

(5) Ascertaining the patient's weight;

(6) Interpretation of laboratory tests or panels; and

(7) Measurement of blood pressure;

J. Office visits solely for the administration of injectable medications, unless medical necessity and the patient's inability to take appropriate oral medications are documented in the medical record;

K. More than one visit per day to the same freestanding clinic, unless the additional visit is adequately documented as:

(1) An emergency situation; or

(2) A visit to a different specialty;

L. Central nervous system stimulants and anorectic agents when used for weight control;

M. Immunizations required solely for travel outside the continental United States;

N. Vision care services excluded under COMAR 10.09.14 or COMAR 10.09.23;

O. Separate billing for services which are specifically included as part of another service;

P. Separate reimbursement to a practitioner for services provided in a freestanding clinic in addition to the freestanding clinic reimbursement;

Q. Payment for more than one visit to complete an EPSDT screening service;

R. Visits solely for group or individual health education;

S. Freestanding clinic visits in addition to an EKG procedure when the EKG procedure is the only purpose for the visit; and

T. Services for which preauthorization is required under Regulation .09 of this chapter but has not been obtained.

Md. Code Regs. 10.09.08.06

Regulations .06 repealed effective October 1, 1985 (12:19 Md. R. 1849)
Regulations .06 adopted effective October 1, 1985 (12:19 Md. R. 1849)
Regulation .06 amended effective May 23, 1994 (21:10 Md. R. 844)
Regulation .06G amended effective October 14, 2013 (40:20 Md. R. 1652)
Regulation .06 adopted effective 42:6 Md. R. 512, eff.4/1/2015; amended effective 50:20 Md. R. 886, eff. 10/16/2023