Page 17

State of Maryland Medical Assistance Manual Revised April 2014

There is no deduction for non-covered services received during a penalty period; therefore, the amount deducted is $0. For services received during ineligible months, the provider’s charge is deducted. For non- covered services received when the recipient is MA eligible, the lesser of the provider’s charge or the Medicaid fee is deducted. If a Medicaid fee is not established, the provider’s charge is deducted. Requests for pre-eligibility medical expenses (PEME) submitted at the time of the MA-LTC application will be deducted beginning in the first month of eligibility. Requests for non-covered services submitted during periods of eligibility will be deducted beginning in the month the request and required documentation was submitted, as this is an interim change. The deduction, when added to all other deductions, may not exceed the recipient’s total countable income for the month. To determine the allowable deduction, the CM sends a completed OES 001, a self-addressed envelope, a copy of the CARES STAT Screen for all denied months, and a copy of the detailed itemized current bill, receipt, or contract to: DHMH 201 West Preston Street, Room SS-10 Baltimore, MD 21201 Attn: Non-Covered Services

The bill, receipt, or contract must contain all of the following: 1. The providers name, address and telephone number; 2. The A/R’s name that received the service (s); 3. A service date; 4. The amount(s) charged: • Per service; and • Per date; 5. Detailed description of the item or service: 6. Applicable service code(s) for each of the following services: • Dental services; • Podiatry services; • Audiology services; • Vision services; and 7. All payments received by the provider for the charges billed.