Page 129

COMAR 10.09.24.01-.16 1729 State of Maryland Medical Assistance Manual Revised July 2012

(4) A recipient utilizes a Medical Assistance card in an inappropriate manner.

B. Examples. The following are examples of circumstances that may be recipient abuse:

(1) Misrepresenting to a provider material facts regarding symptoms, circumstances, or treatment by other providers;

(2) Failing to affirmatively disclose to a provider any treatment or services being provided by another provider;

(3) Losing or failing to maintain security sufficient to prevent loss or theft of more than one Medical Assistance card during a certification period;

(4) Utilizing an emergency room of a hospital or a specialty outpatient clinic of a hospital as a primary care provider when primary care providers are available in the service area in which the recipient resides;

(5) Underutilizing the appropriate providers for the proper care and management of an existing health condition;

(6) Obtaining medications that require close physician monitoring while not appropriately using the physician services which could provide the monitoring;

(7) Using or maintaining custody or possession of a Medical Assistance card in such a manner that it is used for an unauthorized or illegal purpose.

C. Procedures.

(1) The Division of Utilization and Eligibility Review, Medical Care Compliance Administration, shall determine whether recipient abuse exists using the procedures in §C(2)— (8) of this regulation.

(2) Cases may be reviewed on the basis of statistical reports, outside complaints, referrals from other agencies, or other appropriate sources.

(3) A preliminary review shall be conducted to determine whether the recipient's alleged or noted behavior is of the form specified under §A(1)—(3) of this regulation or is of the form specified under §A(4) of this regulation.

(4) If the alleged or noted behavior is one of the types listed in §A(1)—(3) of this regulation, all relevant and available information shall be forwarded for medical review as specified under §B(5) of this regulation.

(5) If the alleged or likely behavior is of the type listed in §A(4) of this regulation, all relevant and available information shall be forwarded for administrative review as specified under §C(7) of this regulation.

(6) When a case is referred for medical review, a medical professional employed by the Program shall determine whether the recipient's use of medical services constitutes abuse, as defined