Ch. 35

1997 LAWS OF MARYLAND

REPRESENTATION IT PLACES BEFORE THE PUBLIC THAT THE NONPROFIT HEALTH
SERVICE PLAN IS A PRIVATE NOT-FOR-PROFIT CORPORATION.

REVISOR'S NOTE: This section is new language derived without substantive
change from former Art. 48A, § 354A-2.

14-104. STATEMENT OF PRINCIPAL CLAIMS PRACTICES.

(A) REQUIRED.

EACH NONPROFIT HEALTH SERVICE PLAN THAT PROVIDES HOSPITAL
BENEFITS SHALL FURNISH A STATEMENT OF THE PLAN'S PRINCIPAL CLAIMS
PRACTICES AS PART OF THE CERTIFICATE FORM OR BOOKLET DESCRIBING THE
COVERAGE TO BE AFFORDED.

(B) CONTENTS.

THE STATEMENT SHALL INCLUDE PRACTICES FOR PAYMENT FOR:

(1) SURGICAL PROCEDURES PERFORMED BY TWO OR MORE
SURGEONS;

(2) SERVICES PROVIDED IN-AREA BY NONPARTICIPATING PROVIDERS;

AND

(3) SERVICES PROVIDED OUT-OF-AREA BY AFFILIATED PLANS AND
AFFILIATED PROVIDERS.

REVISOR'S NOTE: This section is new language derived without substantive
change from former Art. 48A, § 354P.

14-105. FRAUDULENT HEALTH INSURANCE CLAIMS.

(A) RECOVERY OF COSTS AND EXPENSES — BY NONPROFIT HEALTH SERVICE

PLAN.

IF A NONPROFIT HEALTH SERVICE PLAN IS SUCCESSFUL IN AN ACTION
AGAINST A PERSON AUTHORIZED TO PROVIDE HEALTH CARE IN THE STATE, THE
NONPROFIT HEALTH SERVICE PLAN MAY RECOVER THE COSTS AND EXPENSES
REASONABLY INCURRED BY IT IN THE ACTION IF IT SHOWS THAT:

(1) THE PERSON KNOWINGLY OR WILLFULLY MADE OR CAUSED TO BE

MADE:

(I) A FALSE STATEMENT OR REPRESENTATION OF A MATERIAL
FACT IN AN APPLICATION FOR A BENEFIT OR PAYMENT FROM A NONPROFIT
HEALTH SERVICE PLAN UNDER THIS SUBTITLE OR TITLE 15 OF THIS ARTICLE;

(II) A FALSE STATEMENT OR REPRESENTATION OF A MATERIAL
FACT FOR USE IN DETERMINING RIGHTS TO THOSE BENEFITS OR PAYMENTS; OR

(III) A FALSE STATEMENT OR REPRESENTATION ABOUT A
PROCEDURE, OPERATION, OR SERVICE ALLEGED TO HAVE BEEN PERFORMED; OR

(2) THE PERSON:

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