2016 Maryland Code
Insurance
Title 15 - Health Insurance
Subtitle 10 - Claims and Utilization Review
§ 15-1009. "Carrier" defined; reimbursement for preauthorized care; payment of claims

MD Ins Code § 15-1009 (2016) What's This?

(a) "Carrier" defined. -- In this section, "carrier" means:

(1) an insurer;

(2) a nonprofit health service plan;

(3) a health maintenance organization;

(4) a dental plan organization; or

(5) any other person that provides health benefit plans subject to regulation by the State.

(b) Reimbursement for preauthorized care. -- If a health care service for a patient has been preauthorized or approved by a carrier or the carrier's private review agent, the carrier may not deny reimbursement to a health care provider for the preauthorized or approved service delivered to that patient unless:

(1) the information submitted to the carrier regarding the service to be delivered to the patient was fraudulent or intentionally misrepresentative;

(2) critical information requested by the carrier regarding the service to be delivered to the patient was omitted such that the carrier's determination would have been different had it known the critical information;

(3) a planned course of treatment for the patient that was approved by the carrier was not substantially followed by the health care provider; or

(4) on the date the preauthorized or approved service was delivered:

(i) the patient was not covered by the carrier;

(ii) the carrier maintained an automated eligibility verification system that was available to the contracting provider by telephone or via the Internet; and

(iii) according to the verification system, the patient was not covered by the carrier.

(c) Suspension of review of claims. -- Notwithstanding subsection (b) of this section, a carrier may suspend review of a claim for reimbursement of a preauthorized or approved health care service if:

(1) the patient is in the second or third month of a grace period under 45 C.F.R. § 156.270(d);

(2) the carrier maintains an automated eligibility verification system that was available to the health care provider by telephone or via the Internet at the time the health care service was provided;

(3) according to the verification system, the provider is informed that:

(i) the patient is in the second or third month of a grace period and review of a claim for reimbursement may be suspended; and

(ii) a carrier is not prohibited from denying a claim for reimbursement of a suspended claim; and

(4) the carrier complies with the notice and claim payment requirements under § 15-1005 of this subtitle.

(d) Payment of claims. -- A carrier shall pay a claim for a preauthorized or approved covered health care service in accordance with §§ 15-1005 and 15-1008 of this subtitle.

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