2010 Maryland Code
HEALTH - GENERAL
TITLE 19 - HEALTH CARE FACILITIES
Subtitle 1 - Health Care Planning and Systems Regulation
Section 19-134 - Medical care electronic claims clearinghouses.

§ 19-134. Medical care electronic claims clearinghouses.
 

(a)  Established; regulations; limitations; licensing fee; electronic transmissions.-  

(1) In order to more efficiently establish a medical care data base under § 19-133 of this subtitle, the Commission shall establish standards for the operation of one or more medical care electronic claims clearinghouses in Maryland and may license those clearinghouses meeting those standards. 

(2) In adopting regulations under this subsection, the Commission shall consider appropriate national standards. 

(3) The Commission may limit the number of licensed claims clearinghouses to assure maximum efficiency and cost effectiveness. 

(4) The Commission, by regulation, may charge a reasonable licensing fee to operate a licensed claims clearinghouse. 

(5) Health care practitioners in Maryland, as designated by the Commission, shall submit, and payors of health care services in Maryland as designated by the Commission shall receive claims for payment and any other information reasonably related to the medical care data base electronically in a standard format as required by the Commission whether by means of a claims clearinghouse or other method approved by the Commission. 

(6) The Commission shall establish reasonable deadlines for the phasing in of electronic transmittal of claims from those health care practitioners designated under paragraph (5) of this subsection. 

(7) As designated by the Commission, payors of health care services in Maryland and Medicaid and Medicare shall transmit explanations of benefits and any other information reasonably related to the medical care data base electronically in a standard format as required by the Commission whether by means of a claims clearinghouse or other method approved by the Commission. 

(b)  Medical care claims information.- The Commission may collect the medical care claims information submitted to any licensed claims clearinghouse for use in the data base established under § 19-133 of this subtitle. 

(c)  Comparative evaluation of quality of care outcomes and performance measurements of health maintenance organization benefit plans and services.-  

(1) The Commission shall: 

(i) Establish and implement a system to comparatively evaluate the quality of care outcomes and performance measurements of health maintenance organization benefit plans and services on an objective basis; and 

(ii) Annually publish the summary findings of the evaluation. 

(2) The purpose of a comparable performance measurement system established under this subsection is to assist health maintenance organization benefit plans to improve the quality of care provided by establishing a common set of performance measurements and disseminating the findings of the performance measurements to health maintenance organizations and interested parties. 

(3) The system, where appropriate, shall: 

(i) Solicit performance information from enrollees of health maintenance organizations; and 

(ii) On or before October 1, 2007, to the extent feasible, incorporate racial and ethnic variations. 

(4) (i) The Commission shall adopt regulations to establish the system of evaluation provided under this subsection. 

(ii) Before adopting regulations to implement an evaluation system under this subsection, the Commission shall consider any recommendations of the quality of care subcommittee of the Group Health Association of America and the National Committee for Quality Assurance. 

(5) The Commission may contract with a private, nonprofit entity to implement the system required under this subsection provided that the entity is not an insurer. 

(6) The annual evaluation summary required under paragraph (1) of this subsection shall: 

(i) Include a summary of the Drug Formulary Accreditation Standards of the National Committee for Quality Assurance (NCQA); 

(ii) Indicate whether the formulary development process of each health maintenance organization evaluated complies with the National Committee for Quality Assurance (NCQA) accreditation standards; and 

(iii) Include to the extent feasible information on racial and ethnic variations. 

(d)  Comparative evaluation of quality of care and performance of nursing facilities.-  

(1) The Commission, in consultation with the Department of Health and Mental Hygiene and the Department of Aging, shall: 

(i) On or before July 1, 2001, develop and implement a system to comparatively evaluate the quality of care and performance of nursing facilities on an objective basis; and 

(ii) Annually publish the summary findings of the evaluation. 

(2) (i) The purpose of the comparative evaluation system established under this subsection is to improve the quality of care provided by nursing facilities by establishing a common set of performance measures and disseminating the findings of the comparative evaluation to nursing facilities, consumers, and other interested parties. 

(ii) In developing the comparative evaluation system, the Commission shall consider the health status of the population served. 

(3) (i) The system, as appropriate, shall solicit performance information from consumers and their families. 

(ii) On or before October 1, 2007, to the extent feasible, the system shall incorporate racial and ethnic variations. 

(4) The Commission may adopt regulations to establish the comparative evaluation system provided under this subsection. 

(e)  Comparative evaluation of quality of care outcomes and performance measurements of hospitals and ambulatory surgical facilities.-  

(1) The Commission may: 

(i) On or before July 1, 2001, develop and implement a system to comparatively evaluate the quality of care outcomes and performance measurements of hospitals and ambulatory surgical facilities on an objective basis; and 

(ii) Annually publish the summary findings of the evaluation. 

(2) (i) The purpose of a comparable performance measurement system established under this subsection is to improve the quality of care provided by hospitals and ambulatory surgical facilities by establishing a common set of performance measurements and disseminating the findings of the performance measurements to hospitals, ambulatory surgical facilities, consumers, and interested parties. 

(ii) In developing the performance measurement system, the Commission shall consider the geographic location, urban or rural orientation, and teaching or nonteaching status of the hospital and the ambulatory surgical facilities, and the health status of the population served. 

(3) (i) The system, where appropriate, shall solicit performance information from consumers. 

(ii) On or before October 1, 2007, to the extent feasible, the system shall incorporate racial and ethnic variations. 

(4) (i) The Commission may adopt regulations to establish the system of evaluation provided under this subsection. 

(ii) Before adopting regulations to implement an evaluation system under this subsection, the Commission shall: 

1. Consider the performance measurements of appropriate accreditation organizations, State licensure regulations, Medicare certification regulations, the quality indicator project of the Association of Maryland Hospitals and Health Systems, and any other relevant performance measurements; 

2. Evaluate the desirability and feasibility of developing a consumer clearinghouse on health care information using existing available data; and 

3. On or before January 1, 2001, report to the General Assembly, subject to § 2-1246 of the State Government Article, on any performance evaluation developed under this subsection. 

(5) The Commission may contract with a private entity to implement the system required under this subsection provided that the entity is not a hospital or an ambulatory surgical facility. 

(6) (i) The comparable evaluation system established under this subsection shall include health care-associated infection information from hospitals. 

(ii) The comparable evaluation system shall adhere, to the extent possible, to the current recommendations of the federal Centers for Disease Control and Prevention (CDC) and the CDC Healthcare Infection Control Practices Advisory Committee regarding public reporting of health care-associated infections. 

(f)  Compilation and evaluation of data on racial and ethnic disparities.-  

(1) The Commission shall compile data on: 

(i) Racial and ethnic disparities in insurance coverage for low-income, nonelderly individuals; 

(ii) The racial and ethnic composition of the physician population compared to the racial and ethnic composition of the State's population; and 

(iii) Morbidity and mortality rates based on race and ethnicity for cardiovascular disease, cancer, diabetes, HIV/AIDS, infant mortality, asthma, and other diseases the Commission identifies. 

(2) The Commission shall: 

(i) Provide the racial and ethnic information compiled under this subsection to the Office of Minority Health and Health Disparities; and 

(ii) Analyze the information jointly with the Office of Minority Health and Health Disparities for publication in the "Health Care Disparities Policy Report Card" required under § 20-1004(22) of this article. 

(3) (i) The Commission shall evaluate the feasibility of obtaining information from urban and rural populations in order to identify geographic disparities. 

(ii) If the Commission is able to obtain the information described in subparagraph (i) of this paragraph, the Commission shall provide the information to the Office of Minority Health and Health Disparities. 

(g)  Source of racial and ethnic information.- For purposes of this section, the Commission shall collect racial and ethnic information and data that is reasonably collectable from any national, State, or county source that is reasonably available. 
 

[1993, ch. 9, § 1; 1994, ch. 258, § 1; 1995, ch. 341; 1999, ch. 382, § 2; ch. 383, § 2; chs. 657, 676; ch. 702, § 2; 2000, ch. 61, § 1; 2001, ch. 565, §§ 1, 2; 2004, ch. 356; 2006, chs. 42, 450; 2008, ch. 36.]