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PARRIS N. GLENDENING, Governor
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Ch. 248
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(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.
(e) (D) Except as provided in subsection (d) (E) of this section, a carrier that
does not comply with the provisions of subsection (b) (C) 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].
(d) (E) (1) The provisions of subsection (b)(1) (C)(1) of this section do not
apply if A CARRIER RETROACTIVELY DENIES REIMBURSEMENT TO A HEALTH CARE
PROVIDER BECAUSE:
(i) a carrier retroactively denies reimbursement to a health care
provider because the information submitted to the carrier was fraudulent or
improperly coded; and;
(ii) in the case of improper coding, THE INFORMATION SUBMITTED
TO THE CARRIER WAS IMPROPERLY CODED AND the carrier has provided to the
health care provider sufficient information regarding the coding guidelines used by
the carrier at least 30 days prior to the date the services subject to the retroactive
denial were rendered; OR
(III) THE CLAIM SUBMITTED TO THE CARRIER WAS A DUPLICATE
CLAIM.
(2) Information submitted to the carrier may be considered to be
improperly coded under paragraph (1) of this subsection if the information submitted
to the carrier by the health care provider:
(i) uses codes that do not conform with the coding guidelines used
by the carrier applicable as of the date the service or services were rendered; or
(ii) does not otherwise conform with the contractual obligations of
the health care provider to the carrier applicable as of the date the service or services
were rendered.
(e) (F) If a carrier retroactively denies reimbursement for services as a
result of coordination of benefits under provisions of subsection (b)(1)(i) (C)(1)(I) of this
section, the health care provider shall have 6 months from the date of denial, unless
a carrier permits a longer time period, to submit a claim for reimbursement for the
service to the carrier, Maryland Medical Assistance Program, or Medicare Program
responsible for payment.
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- 1545 -
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