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Ch. 248 2000 LAWS OF MARYLAND
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(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) "Code" means:
(i) the applicable current procedural terminology (CPT) code, as
adopted by the American Medical Association;
(ii) if for a dental service, the applicable code adopted by the
American Dental Association; or
(iii) another applicable code under an appropriate uniform coding
scheme used by a carrier in accordance with this section.
(4) "Coding guidelines" means those standards or procedures used or
applied by a payor to determine the most accurate and appropriate code or codes for
payment by the payor for a service or services.
(5) "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.
(6) "REIMBURSEMENT" MEANS PAYMENTS MADE TO A HEALTH CARE
PROVIDER BY A CARRIER ON EITHER A FEE-FOR-SERVICE, CAPITATED, OR PREMIUM
BASIS.
(B) THIS SECTION DOES NOT APPLY TO AN ADJUSTMENT TO REIMBURSEMENT
MADE AS PART OF AN ANNUAL CONTRACTED RECONCILIATION OF A RISK SHARING
ARRANGEMENT UNDER AN ADMINISTRATIVE SERVICE PROVIDER CONTRACT.
(b) (C) (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 fehe-ck»m-oubmittod 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.
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- 1544 -
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