|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PARRIS N. GLENDENING, Governor
|
|
Ch. 275
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(4) "Adjunct claims documentation" means an abstract of an enrollee's
medical record which describes and summarizes the diagnosis and treatment of, and
services rendered to, the enrollee.
(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 THE GREATER OF:
A. 125% OF THE RATE THE HEALTH MAINTENANCE
ORGANIZATION PAYS IN THE SAME GEOGRAPHIC AREA, FOR THE SAME COVERED
SERVICE, TO A SIMILARLY LICENSED PROVIDER UNDER WRITTEN CONTRACT WITH
THE HEALTH MAINTENANCE ORGANIZATION; OR
B. THE RATE AS OF JANUARY 1, 2000 THAT THE HEALTH
MAINTENANCE ORGANIZATION PAID IN THE SAME GEOGRAPHIC AREA. FOR THE
SAME COVERED SERVICE, TO A SIMILARLY LICENSED PROVIDER NOT UNDER
WRITTEN CONTRACT WITH THE HEALTH MAINTENANCE ORGANIZATION.
(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) SHALL BEAR THE BURDEN OF PROVING THAT ITS PAYMENT IS
AT THE USUAL, CUSTOMARY, AND REASONABLE RATE; AND
[(ii)] (III) On request of the health care provider, shall disclose the
methodology used to determine the amount of payment.
(2) A HEALTH MAINTENANCE ORGANIZATION SHALL DISCLOSE, ON
REQUEST OF A HEALTH CARE PROVIDER NOT UNDER WRITTEN CONTRACT WITH THE
HEALTH MAINTENANCE ORGANIZATION, THE REIMBURSEMENT RATE REQUIRED
UNDER PARAGRAPH (1)(II)2 OF THIS SUBSECTION.
|
|
|
|
|
|
|
|
|
|
- 1635 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
