Ch. 199

1997 LAWS OF MARYLAND

(b) (1) In addition to any other provisions of this subtitle, for a covered service
rendered to an enrollee of a health maintenance organization by a health care provider
not under written contract with the health maintenance organization, the health
maintenance organization or its agent:

(i) Shall pay the health care provider within 30 days after the receipt
of a claim in accordance with the applicable provisions of this subtitle; and

(ii) Shall pay the claim submitted by:

1. A hospital at the rate approved by the Health Services Cost
Review Commission; and

2. Any other health care provider at the rate billed or at the
usual, customary, and reasonable rate.

(2) A health maintenance organization that pays a health care provider at
the usual, customary, and reasonable rate:

(i) Except for services rendered to medical assistance recipients OR
FOR SERVICES RENDERED UNDER A CONTRACT ENTERED INTO UNDER § 1876(G) OF
THE FEDERAL SOCIAL SECURITY ACT (42 U.S.C. § 1395MM), may not use Medicare,
Medicaid, or workers' compensation payments as part of any methodology used to
determine a payment at the usual, customary, and reasonable rate; and

(ii) On request of the health care provider, shall disclose the
methodology used to determine the amount of payment.

(c) (1) A health maintenance organization may seek reimbursement from an
enrollee for any payment under subsection (b) of this section for a claim or portion of a
claim submitted by a health care provider and paid by the health maintenance
organization that the health maintenance organization determines is the responsibility of
the enrollee.

(2) The health maintenance organization may request and the health care
provider shall provide adjunct claims documentation to assist in making the
determination under paragraph (1) of this subsection or under subsection (b) of this
section.

(d) In addition to any other penalties under this subtitle, the Commissioner may
impose a penalty not to exceed $5,000 on any health maintenance organization which
violates the provisions of this section if the violation is committed with such frequency as
to indicate a general business practice of the health maintenance organization.

SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect
October 1. 1997.

Approved April 29, 1997.

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