PARRIS N. GLENDENING, Governor

Ch. 163

(2) "Carrier" means:
(i) an insurer;

(ii) a nonprofit health service plan;
(iii) a health maintenance organization;
(iv) a dental plan organization; or

(v) any other person that provides health benefit plans subject to
regulation by the State.

(3) "Health care practitioner" means an individual who is licensed, certified,
or otherwise authorized under the Health-Occupations Article to provide health care
services.

(b) A carrier may not reimburse a health-care practitioner in an amount less than
the sun or rate negotiated in the carrier's provider contract with the health care
practitioner.

(C) (1) IF A CARRIER RETROACTIVELY DENIES REIMBURSEMENT TO A
HEALTH CARE PRACTITIONER, THE CARRIER:

(I) MAY ONLY RETROACTIVELY DENY REIMBURSEMENT DURING
THE 6-MONTH PERIOD AFTER THE DATE THAT THE HEALTH CARE PRACTITIONER
SUBMITTED THE CLAIM TO THE CARRIER FOR REIMBURSEMENT; AND

(II) SHALL PROVIDE THE HEALTH-CARE PRACTITIONER WITH A
WRITTEN STATEMENT SPECIFYING THE BASIS FOR THE RETROACTIVE DENIAL.

(2) EXCEPT IN CASES OF FRAUD OR IMPROPER CODING BY A HEALTH
CARE PRACTITIONER, A CARRIER THAT DOES NOT COMPLY WITH THE PROVISIONS
OF PARAGRAPH (1) OF THIS SUBSECTION MAY NOT RETROACTIVELY DENY
REIMBURSEMENT OR ATTEMPT IN ANY MANNER TO RETROACTIVELY COLLECT
REIMBURSEMENT ALREADY PAID TO A HEALTH-CARE PRACTITIONER BY REDUCING
REIMBURSEMENTS CURRENTLY OWED TO THE HEALTH-CARE PRACTITIONER,
WITHHOLDING FUTURE REIMBURSEMENT, OR IN ANY OTHER MANNER AFFECTING
THE FUTURE REIMBURSEMENT TO THE HEALTH CARE PRACTITIONER.

[(c)](D) This section does not prohibit a carrier from providing bonuses or other
incentive based compensation to a health care practitioner if the bonus or other
incentive-based compensation does not:

(1) violate § 19-705.1 of the Health—General Article; or

(2) deter the delivery of medically appropriate care to an enrollee.

15-1008.

(A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.

(2) "CARRIER" MEANS:

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