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Ch. 276 2005 LAWS OF MARYLAND
Article - Insurance
15-1005.
(a) In this section, "clean claim" means a claim for reimbursement, as defined
in regulations adopted by the Commissioner under § 15-1003 of this subtitle.
(b) To the extent consistent with the Employee Retirement Income Security
Act of 1974 (ERISA), 29 U.S.C. 1001, et seq., this section applies to an insurer,
nonprofit health service plan, or health maintenance organization that acts as a third
party administrator.
(c) Within 30 days after receipt of a claim for reimbursement from a person
entitled to reimbursement under § 15-701(a) of this title or from a hospital or related
institution, as those terms are defined in § 19-301 of the Health — General Article, an
insurer, nonprofit health service plan, or health maintenance organization shall:
(1) mail or otherwise transmit payment for the claim in accordance with
this section; or
(2) send a notice of receipt and status of the claim that states:
(i) that the insurer, nonprofit health service plan, or health
maintenance organization refuses to reimburse all or part of the claim and the reason
for the refusal;
(ii) that, in accordance with § 15-1003(d)(1)(ii) of this subtitle, the
legitimacy of the claim or the appropriate amount of reimbursement is in dispute and
additional information is necessary to determine if all or part of the claim will be
reimbursed and what specific additional information is necessary; or
(iii) that the claim is not clean and the specific additional
information necessary for the claim to be considered a clean claim.
(d) (1) An insurer, nonprofit health service plan, or health maintenance
organization shall permit a provider a minimum of 180 days from the date a covered
service is rendered to submit a claim for reimbursement for the service.
(2) If an insurer, nonprofit health service plan, or health maintenance
organization wholly or partially denies a claim for reimbursement, the insurer,
nonprofit health service plan, or health maintenance organization shall permit a
provider a minimum of 90 working days after the date of denial of the claim to appeal
the denial.
(3) IF AN INSURER, NONPROFIT HEALTH SERVICE PLAN, OR HEALTH
MAINTENANCE ORGANIZATION ERRONEOUSLY DENIES A PROVIDER'S CLAIM FOR
REIMBURSEMENT SUBMITTED WITHIN THE TIME PERIOD SPECIFIED IN PARAGRAPH
(1) OF THIS SUBSECTION BECAUSE OF A CLAIMS PROCESSING ERROR, AND THE
PROVIDER NOTIFIES THE INSURER NONPROFIT HEALTH SERVICE PLAN, OR HEALTH
MAINTENANCE ORGANIZATION OF THE POTENTIAL ERROR WITHIN 1 YEAR OF THE
CLAIM DENIAL, THE INSURER, NONPROFIT HEALTH SERVICE PLAN, OR HEALTH
MAINTENANCE ORGANIZATION, ON DISCOVERY OF THE ERROR, SHALL REPROCESS
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