PARRIS N. GLENDENING, Governor

Ch. 35

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

(2) "HEALTH CARE PRACTITIONER" HAS THE MEANING STATED IN §
1-301 OF THE HEALTH OCCUPATIONS ARTICLE.

(3) "HEALTH CARE SERVICE" HAS THE MEANING STATED IN § 1-301 OF
THE HEALTH OCCUPATIONS ARTICLE.

(4) "PROHIBITED REFERRAL" MEANS A REFERRAL PROHIBITED BY §
1-302 OF THE HEALTH OCCUPATIONS ARTICLE.

(B) SCOPE OF SECTION.

THIS SECTION APPLIES TO INSURERS AND NONPROFIT HEALTH SERVICE PLANS
THAT ISSUE OR DELIVER INDIVIDUAL OR GROUP HEALTH INSURANCE POLICIES IN
THE STATE.

(C) REPAYMENT FOR PROHIBITED REFERRALS.

AN ENTITY SUBJECT TO THIS SECTION MAY SEEK REPAYMENT FROM A HEALTH
CARE PRACTITIONER OF ANY MONEYS PAID FOR A CLAIM, BILL, OR OTHER DEMAND
OR REQUEST FOR PAYMENT FOR HEALTH CARE SERVICES THAT THE APPROPRIATE
REGULATORY BOARD DETERMINES WERE PROVIDED AS A RESULT OF A
PROHIBITED REFERRAL.

(D) REQUIRED PROVISIONS.

EACH INDIVIDUAL AND GROUP HEALTH INSURANCE POLICY THAT IS ISSUED
FOR DELIVERY IN THE STATE BY AN ENTITY SUBJECT TO THIS SECTION AND THAT
PROVIDES COVERAGE FOR HEALTH CARE SERVICES SHALL INCLUDE A PROVISION
THAT EXCLUDES PAYMENT OF ANY CLAIM, BILL, OR OTHER DEMAND OR REQUEST
FOR PAYMENT FOR HEALTH CARE SERVICES THAT THE APPROPRIATE
REGULATORY BOARD DETERMINES WERE PROVIDED AS A RESULT OF A
PROHIBITED REFERRAL.

(E) REPORTING REQUIREMENTS.

AN ENTITY SUBJECT TO THIS SECTION SHALL REPORT TO THE COMMISSIONER
AND THE APPROPRIATE REGULATORY BOARD ANY PATTERN OF CLAIMS, BILLS, OR
OTHER DEMANDS OR REQUESTS FOR PAYMENT SUBMITTED FOR HEALTH CARE
SERVICES PROVIDED AS A RESULT OF A PROHIBITED REFERRAL WITHIN 30 DAYS
AFTER THE ENTITY HAS KNOWLEDGE OF THE PATTERN.

(F) AUDITS OR INVESTIGATIONS.

(1) NOTWITHSTANDING ANY OTHER PROVISION OF THIS SECTION, AN
ENTITY SUBJECT TO THIS SECTION THAT REIMBURSES FOR HEALTH CARE SERVICES
IS NOT REQUIRED TO AUDIT OR INVESTIGATE A CLAIM, BILL, OR OTHER DEMAND
OR REQUEST FOR PAYMENT FOR HEALTH CARE SERVICES TO DETERMINE
WHETHER THOSE SERVICES WERE PROVIDED AS A RESULT OF A PROHIBITED
REFERRAL.

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