Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 3 › Subtitle 14 - CANCER CONTROL › Chapter 10.14.02 - Reimbursement for Breast and Cervical Cancer Diagnosis and Treatment › Section 10.14.02.04 - Physician Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. To be
				  considered a participating physician in the Program, the provider shall:
(1) Provide a medical procedure or service
				  related to the diagnosis and treatment of breast cancer, cervical cancer, or a
				  precancerous cervical lesion;
(2)
				  Have a current license to practice medicine in Maryland or a jurisdiction
				  bordering Maryland;
(3) Agree to
				  accept, for each covered medical procedure performed or service provided, the
				  following reimbursement including, if applicable, a medical management fee as
				  described in Regulation .15 of this chapter:
(a) The current Medical Assistance approved
				  rate in the State for an eligible patient who is uninsured or who has insurance
				  that does not provide coverage for a reimbursed procedure or service;
(b) The reimbursement rate approved by the
				  insurer plus the payment of the outstanding deductible and patient contribution
				  amount by the Department for an eligible patient who has insurance, other than
				  Medicare, that provides coverage for a reimbursed procedure or
				  service;
(c) The reimbursement rate
				  approved by Medicare plus the payment of the outstanding deductible and the
				  patient contribution amount by the Department for an eligible patient who is
				  covered by Medicare; or
(d) For an
				  eligible patient who has insurance that provides reimbursement for a covered
				  procedure or service that is less than the current Medical Assistance approved
				  rate, the reimbursement rate approved by the insurer plus the difference
				  between the reimbursement rate approved by the insurer and the current Medical
				  Assistance approved rate in the State plus the payment of the outstanding
				  deductible by the Department;
(4) Agree to abide by the provisions set
				  forth in §A of this regulation by signing and sending to the Department
				  the designated Departmental form;
(5) Agree not to bill an eligible patient,
				  who is uninsured or is covered by Medicare or other insurance, for an
				  additional charge for the reimbursed medical procedure performed or service
				  provided;
(6) Agree to:
(a) Be the medical case manager for an
				  eligible patient; or
(b) Coordinate
				  the reimbursed medical procedure or service with the designated medical case
				  manager and submit the result of the procedure to the medical case
				  manager;
(7) Agree to
				  the following medical guidelines:
(a) That a
				  negative mammogram alone is not sufficient to evaluate a clinically significant
				  mass, and to perform or arrange for further diagnostic evaluation of the
				  mass;
(b) That a surgeon shall
				  examine the patient and make the final determination of further diagnostic and
				  treatment procedures needed when a needle biopsy performed by a non-surgeon is
				  negative for cancer;
(c) To
				  perform or arrange for needle localization of the mass before excisional
				  biopsy;
(d) To perform or arrange
				  for radiological examination of the breast surgical specimen after biopsy to
				  accurately identify the mass;
(e)
				  To refer an eligible patient with a mammography assessment recommending biopsy
				  to a surgeon for evaluation and a decision regarding the ultimate course of
				  action;
(f) To implement the
				  diagnostic tests or procedures required for cancer staging determination in
				  keeping with the best interests of the patient and to determine staging on the
				  cancer found;
(g) To consult an
				  oncologist before any treatment is initiated for Stage I or greater breast
				  cancer or invasive cervical cancer; and
(h) To consult with a radiation oncologist if
				  radiation treatment is a medical option;
(8) Agree to maintain the result s of the
				  reimbursed medical procedures performed as set forth in §E(6)-(9) of this
				  regulation;
(9) Agree to maintain
				  administrative and health records, including medical records, to document
				  compliance with this chapter for a minimum of 6 years and, upon request, allow
				  the Department access to the records; and
(10) Place no restriction on the eligible
				  patient's right to choose a provider.