Ch. 376

1993 LAWS OF MARYLAND

Article 48A - Insurance Code

354MM.

(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 NONPROFIT HEALTH SERVICE PLAN MAY SEEK REPAYMENT FOR 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 GROUP OR INDIVIDUAL POLICY ISSUED FOR DELIVERY IN THE
STATE WHICH PROVIDES COVERAGE FOR 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 NONPROFIT HEALTH SERVICE PLAN 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 PLAN
HAS KNOWLEDGE OF THAT PATTERN.

(E)     (1) NOTWITHSTANDING THE PROVISIONS OF THIS SECTION, A
NONPROFIT HEALTH SERVICE PLAN 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 A PROHIBITED REFERRAL ARE
NOT GROUNDS TO DELAY PAYMENT OR WAIVE THE PROVISIONS OF § 354Z OF THIS
ARTICLE.

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

470CC.

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

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