H.B. 617                                                 VETOES

(III) AT THE RATE APPROVED BY THE HEALTH SERVICES COST
REVIEW COMMISSION FOR A HOSPITAL THAT IS NOT UNDER WRITTEN CONTRACT
WITH THE HEALTH MAINTENANCE ORGANIZATION.

(2) A HEALTH CARE PROVIDER MAY NOT BE REQUIRED TO OBTAIN
PRIOR AUTHORIZATION OR A CERTIFICATE OF APPROVAL FOR PAYMENT FROM A
HEALTH MAINTENANCE ORGANIZATION IN ORDER TO OBTAIN REIMBURSEMENT
UNDER PARAGRAPH (1) OF THIS SUBSECTION.

(3) (I) A HEALTH CARE PROVIDER OR A DESIGNEE OF A HEALTH
CARE PROVIDER SHALL ATTEMPT TO NOTIFY AN ENROLLEE OR SUBSCRIBER'S
HEALTH MAINTENANCE ORGANIZATION IF COORDINATION OF FURTHER CARE IS
NECESSARY AS SOON AS PRACTICABLE AFTER SERVICES ARE PROVIDED.

(II) A HEALTH CARE PROVIDER IS NOT REQUIRED TO ATTEMPT TO
NOTIFY AN ENROLLEE'S OR SUBSCRIBER'S HEALTH MAINTENANCE ORGANIZATION
IF THE ENROLLEE'S OR SUBSCRIBER'S MEDICAL CONDITION PREVENTED THE
HEALTH CARE PROVIDER FROM DETERMINING THE PATIENT'S INSURANCE STATUS.

(D) The provisions of this section do not apply to claims where:

(1)     There is a good faith dispute regarding:
(i) The legitimacy of the claim; or

(ii) The appropriate amount of reimbursement; and

(2)     The health maintenance organization:

(i) Notifies the provider within 2 weeks of the receipt of the claim that
the legitimacy of the claim or the appropriate amount of reimbursement is in dispute;

(ii) Supplies in writing to the provider the specific reasons why the
legitimacy of the claim, or a portion of the claim, or the appropriate amount of
reimbursement is in dispute;

(iii) Pays any undisputed portion of the claim within 30 days of the
receipt of the claim; and

(iv) Makes a good faith, timely effort to resolve the dispute.

SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect
October 1, 1995.                                                                                         

May 24, 1995

The Honorable Casper R. Taylor, Jr.
Speaker of the House of Delegates
State House
Annapolis MD 21401

Dear Mr. Speaker:

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