WILLIAM DONALD SCHAEFER, Governor Ch. 304
(3) "Covered service" means a health care service included in the benefit
package of the health maintenance organization and rendered to an enrollee of the health
maintenance organization by a health care provider, including a physician or hospital, not
under written contract with the health maintenance organization:
(i) Pursuant to a verbal or written referral by the enrollee's health
maintenance organization or by a provider under written contract with the enrollee's
health maintenance organization; or
(ii) That has been preauthorized or otherwise approved either verbally
or in writing by the enrollee's health maintenance organization or a provider under
written contract with the enrollee's health maintenance organization.
(4) "Adjunct claims documentation" means an abstract of an enrollee's
medical record which describes and summarizes the diagnosis and treatment of, and
services rendered to, the enrollee.
(b) (1) In addition to any other provisions of this subtitle, for a covered service
rendered to an enrollee of a health maintenance organization by a health care provider
not under written contract with the health maintenance organization, the health
maintenance organization or its agent:
(i) Shall pay the health care provider within 30 days after the receipt
of a claim in accordance with the applicable provisions of this subtitle; and
(ii) Shall pay the claim submitted by:
1. A hospital at the rate approved by the Health Services Cost
Review Commission; and
2. Any other health care provider at the rate billed or at the
usual, customary, and reasonable rate.
(2) A HEALTH MAINTENANCE ORGANIZATION THAT PAYS A HEALTH
CARE PROVIDER AT THE USUAL, CUSTOMARY, AND REASONABLE RATE:
(I) EXCEPT FOR SERVICES RENDERED TO MEDICAL ASSISTANCE
RECIPIENTS, MAY NOT USE MEDICARE, MEDICAID, OR WORKERS' COMPENSATION
PAYMENTS AS PART OF ANY METHODOLOGY USED TO DETERMINE A PAYMENT AT
THE USUAL, CUSTOMARY, AND REASONABLE RATE; AND
(II) ON REQUEST OF THE HEALTH CARE PROVIDER, SHALL
DISCLOSE THE METHODOLOGY USED TO DETERMINE THE AMOUNT OF PAYMENT.
(c) (1) A health maintenance organization may seek reimbursement from an
enrollee for any payment under subsection (b) of this section for a claim or portion of a
claim submitted by a health care provider and paid by the health maintenance
organization that the health maintenance organization determines is the responsibility of
the enrollee.
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