WILLIAM DONALD SCHAEFER, Governor                         Ch. 376

Article - Health - General

19-712.4.

(A)     IN THIS SECTION THE TERMS "HEALTH CARE PRACTITIONER", "HEALTH
CARE ENTITY", AND "HEALTH CARE SERVICE" HAVE THE SAME MEANINGS AS
PROVIDED IN § 1-301 OF THE HEALTH OCCUPATIONS ARTICLE.

(B)     A HEALTH MAINTENANCE ORGANIZATION MAY SEEK REPAYMENT FROM
A HEALTH CARE PRACTITIONER OF ANY MONEYS PAID FOR ANY CLAIM, BILL, OR
OTHER DEMAND OR REQUEST FOR PAYMENT FOR THE HEALTH CARE SERVICES
THAT WERE DETERMINED BY THE APPROPRIATE REGULATORY LICENSING BOARD
TO BE FURNISHED AS A RESULT OF A REFERRAL PROHIBITED BY § 1-302 OF THE
HEALTH OCCUPATIONS ARTICLE.

(C)     EVERY CONTRACT BETWEEN A HEALTH MAINTENANCE ORGANIZATION
AND ITS SUBSCRIBERS OR A GROUP OF SUBSCRIBERS FOR THE PROVISION OF
HEALTH CARE SERVICES SHALL INCLUDE A PROVISION EXCLUDING PAYMENT OF
ANY CLAIM, BILL, OR OTHER DEMAND OR REQUEST FOR PAYMENT FOR HEALTH
CARE SERVICES DETERMINED TO BE FURNISHED AS A RESULT OF A REFERRAL
PROHIBITED BY § 1-302 OF THE HEALTH OCCUPATIONS ARTICLE.

(D)     A HEALTH MAINTENANCE ORGANIZATION SUBJECT TO THE PROVISIONS
OF THIS SECTION SHALL REPORT TO THE COMMISSIONER AND THE APPROPRIATE
REGULATORY BOARD ANY PATTERN OF CLAIMS, BILLS OR OTHER DEMANDS OR
REQUESTS FOR PAYMENT SUBMITTED FOR A HEALTH CARE SERVICE PROVIDED AS
A RESULT OF A REFERRAL PROHIBITED BY § 1-302 OF THE HEALTH OCCUPATIONS
ARTICLE WITHIN 30 DAYS AFTER THAT HEALTH MAINTENANCE ORGANIZATION HAS
KNOWLEDGE OF THAT PATTERN.

(E)     (1) NOTWITHSTANDING THE PROVISIONS OF THIS SECTION, A HEALTH
MAINTENANCE ORGANIZATION REIMBURSING FOR HEALTH CARE SERVICES IS NOT
REQUIRED TO AUDIT OR INVESTIGATE ANY CLAIM, BILL, OR OTHER DEMAND OR
REQUEST FOR PAYMENT FOR THE PURPOSE OF DETERMINING WHETHER THOSE
SERVICES WERE THE RESULT OF A PROHIBITED REFERRAL.

(2) ANY AUDIT OR INVESTIGATION OF ANY CLAIM, BILL, OR OTHER
DEMAND OR REQUEST FOR PAYMENT FOR THE PURPOSE OF DETERMINING
WHETHER THOSE SERVICES WERE THE RESULT OF THE PROHIBITED REFERRAL
ARE NOT GROUNDS TO DELAY PAYMENT OR WAIVE THE PROVISIONS OF § 19-712.1
OF THIS SUBTITLE.

(F)     ANY CLAIM, BILL, OR REQUEST FOR PAYMENT THAT IS PAID AND IS
SUBSEQUENTLY DETERMINED TO BE THE RESULT OF A PROHIBITED REFERRAL, A
HEALTH MAINTENANCE ORGANIZATION MAY SEEK A REFUND OF THAT PAYMENT
IN ACCORDANCE WITH THE PROVISIONS OF § 1-305 OF THE HEALTH OCCUPATIONS
ARTICLE.

- 2079 -