Ch. 163 1997 LAWS OF MARYLAND

(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 PROVIDER" MEANS A PERSON OR ENTITY LICENSED,
CERTIFIED OR OTHERWISE AUTHORIZED UNDER THE HEALTH OCCUPATIONS
ARTICLE OR THE HEALTH - GENERAL ARTICLE TO PROVIDE HEALTH CARE
SERVICES.

(B) (1) IF A CARRIER RETROACTIVELY DENIES REIMBURSEMENT TO A
HEALTH CARE PROVIDER, THE CARRIER:

(I) MAY ONLY RETROACTIVELY DENY REIMBURSEMENT FOR
SERVICES SUBJECT TO COORDINATION OF BENEFITS WITH ANOTHER CARRIER, THE
MARYLAND MEDICAL ASSISTANCE PROGRAM, OR THE MEDICARE PROGRAM
DURING THE 18-MONTH PERIOD AFTER THE DATE THAT THE CARRIER PAID THE
CLAIM SUBMITTED BY THE HEALTH CARE PROVIDER; AND

(II) EXCEPT AS PROVIDED IN ITEM (I) OF THIS PARAGRAPH, MAY
ONLY RETROACTIVELY DENY REIMBURSEMENT DURING THE 6-MONTH PERIOD
AFTER THE DATE THAT THE CARRIER PAID THE CLAIM SUBMITTED BY THE HEALTH
CARE PROVIDER.

(2) (I) A CARRIER THAT RETROACTIVELY DENIES REIMBURSEMENT
TO A HEALTH CARE PROVIDER UNDER PARAGRAPH (1) OF THIS SUBSECTION SHALL
PROVIDE THE HEALTH CARE PROVIDER WITH A WRITTEN STATEMENT SPECIFYING
THE BASIS FOR THE RETROACTIVE DENIAL.

(II) IF THE RETROACTIVE DENIAL OF REIMBURSEMENT RESULTS
FROM COORDINATION OF BENEFITS, THE WRITTEN STATEMENT SHALL PROVIDE
THE NAME AND ADDRESS OF THE ENTITY ACKNOWLEDGING RESPONSIBILITY FOR
PAYMENT OF THE DENIED CLAIM.

(C) EXCEPT AS PROVIDED IN SUBSECTION (D) OF THIS SECTION, A CARRIER
THAT DOES NOT COMPLY WITH THE PROVISIONS OF SUBSECTION (B) OF THIS
SECTION MAY NOT RETROACTIVELY DENY REIMBURSEMENT OR ATTEMPT IN ANY
MANNER TO RETROACTIVELY COLLECT REIMBURSEMENT ALREADY PAID TO A
HEALTH CARE PROVIDER BY REDUCING REIMBURSEMENTS CURRENTLY OWED TO
THE HEALTH CARE PROVIDER, WITHHOLDING FUTURE REIMBURSEMENT, OR IN
ANY OTHER MANNER AFFECTING THE FUTURE REIMBURSEMENT TO THE HEALTH
CARE PROVIDER.

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