Medically Indigent Program Reimbursement Fee Schedules for Providers

(a)Reimbursements to Providers and Non-Providers shall be in amounts not to exceed the following:

(1)for in-patient hospital services, the Program shall reimburse services in accordance with the annual Medicare per diem rates set for the hospital’s in-patient services;

(2)for out-patient hospital services, the Program shall reimburse a hospital by applying the annual Medicare hospital specific out-patient cost-to-charge ratio to the covered charges; CH. 2 DIVISION OF PUBLIC WELFARE

(3)for skilled nursing services, the Program shall reimburse at fifty percent (50%) of the annual Medicare per diem rates set for the hospital’s in-patient services;

(4)for intermediate care services, the Program shall reimburse services at sixty percent (60%) of reimbursement rate established in § 2916(a)(3) for skilled nursing;

(5)for professional fees and home health services, the Program shall reimburse services at one hundred percent (100%) of the Medicare Participating Provider fee schedule rate adjusted in accordance with the Hawaii or Guam conversion factor as applicable; and

(6)for dental fees, the National Dental Advisory Schedule shall be used to reimburse services.

(b)The Administrator of the Medically Indigent Program shall have discretionary authority to establish Provider and Non-Provider reimbursement rates for services which are not specifically addressed herein, but which are consistent with the Program services provided by § 2901 through § 2915 of this Article. Said schedules will be developed in conjunction with the Administrator’s duties to secure the necessary Provider and Non-Provider relationships to ensure the availability of adequate medical care and assistance to all Program recipients.

(1)The Program shall not pay claims for Program-covered services that are initially submitted more than twelve

(12)months after the date of the service as clean claims, except for claims submitted for services to members involving the coordination of benefits amongst multiple payers.

(2)Payments shall be made on clean claims in accordance with the reimbursement rates set forth in this Section.

(c)“Clean claims” as defined by this Article and as further defined herein shall mean:

(1)For a Hospital Bill. A hospital bill is considered received for purposes of this Subsection upon initial receipt of the legible claim form by the administration if the claim includes the following errorfree documentation in legible form:

(A)an admission face sheet;

(B)an itemized statement;

(C)an admission history and physical;

(D)a discharge summary or an interim summary if the claim is split;

(E)an emergency record, if admission was through the Emergency Room;

(F)operative reports, if applicable;

(G)a labor and delivery room report, if applicable;

(H)utilization review report.

(2)For Medical Service Claims. For medical service claims, a claim that is submitted on a HCFA 1500 reflecting CPT and HCPCS codes for services and supplies. Services requiring prior authorization shall have a copy of the approved authorization form attached. Specialist services shall have the appropriate referral form attached.

(3)For Dental Claims. For dental claims, a claim that is submitted on the ADA claim form reflecting proper codes for services.

(4)For Behavioral Health Forms. For behavioral health forms, a claim submitted on a HCFA 1500 reflecting CPT codes for behavioral health services. CH. 2 DIVISION OF PUBLIC WELFARE

(d)Payment received by a Provider or Non-Provider from the Program is considered payment by the Program of the Program’s liability for the member’s bill. A Provider may collect any unpaid portion of its bill from other third party payers or the member in the event of non-covered services. A Provider or Nonprovider shall not:

(1)charge, submit a claim to, demand or otherwise collect payment from a member or person who has been determined eligible, unless specifically authorized by this Article or rules adopted pursuant to this Article; or

(2)refer or report a member who has been determined eligible to a collection agency or credit reporting agency for the failure of the member to pay charges for Program covered care or services, unless specifically authorized by this Article or rules adopted pursuant to this Article.

(e)The Administrator may conduct post-payment review of all claims paid by the Program and may recoup any monies erroneously paid.

(1)The Administrator shall adopt rules that specify procedures for conducting post-payment review.

(2)The Program Administrator shall review all prepaid captivated payments and may conduct a post-payment review of all claims paid by the Program, and may recoup monies that are erroneously paid.

(A)Any Provider receiving reimbursements under this Article for which they were not entitled on the basis of false claims filed on behalf of any person receiving assistance under this Article shall be liable for repayment, and shall be guilty of a misdemeanor or felony, depending on the amount paid for which the person was not entitled, as specified in the Criminal and Correctional Code of Guam, Title 9 of the Guam Code Annotated.

(f)Claims for Program-covered services which are determined valid by the Administrator pursuant to § 2907 through § 2912.10, and the Program’s grievance and appeal procedure, shall be paid from the funds established by this Section.

(g)For purposes of this Section, “Program-covered services” exclude administrative charges for operating expenses.

(h)All payments for services established by this Article shall be accounted for by the Administrator by the fiscal year in which the claims were paid, regardless of the fiscal year in which the payments were incurred.

(i)Notwithstanding any other law to the contrary, government-owned Providers are subject to all claims processing and payment requirements or limitations of this Article, which are applicable to nongovernment Providers.

(j)Notwithstanding any law to the contrary, the Director or Administrator may receive confidential adoption information for the purposes of identifying adoption-related third party payers in order to recover the total costs for prenatal care and the delivery of the child, including capitation reinsurance and any feefor-service costs incurred by the Program on behalf of an eligible person who the Administrator has reason to believe had an arrangement to have the eligible person’s newborn adopted.

(1)Except for the sole purpose of identifying adoption-related third party payers, the Administrator shall not further disclose any information obtained pursuant to this Subsection, and shall develop and implement safeguards to protect the confidentiality of this information, including limiting access to the information to only those Program personnel whose official duties require it. CH. 2 DIVISION OF PUBLIC WELFARE

(2)At no time shall the Director or Administrator release to the adoptive parents’ or birth parents’ insurance carrier personally identifying information regarding the other party.

(3)A person who knowingly violates the requirements of this Subsection pertaining to confidentiality is guilty of a Class 6 felony.