|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Ch. 275
|
|
2000 LAWS OF MARYLAND
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(3) THE USUAL, CUSTOMARY, AND REASONABLE RATE IS TILE AMOUNT
AT WHICH 99% OF ALL CLAIMS SUBMITTED TO THE HEALTH MAINTENANCE
ORGANIZATION IN THE PRECEDING CALENDAR YEAR FOR THE SAME SERVICE
WOULD EE PAID IN FULL.
(c) (1) A health maintenance organization may seek reimbursement from an
enrollee for any payment under subsection (b) of this section for a claim or portion of
a claim submitted by a health care provider and paid by the health maintenance
organization that the health maintenance organization determines is the
responsibility of the enrollee.
(2) The health maintenance organization may request and the health
care provider shall provide adjunct claims documentation to assist in making the
determination under paragraph (1) of this subsection or under subsection (b) of this
section.
(D) (1) A HEALTH MAINTENANCE ORGANIZATION SUBSCRIBER OR
ENROLLEE MAY ENTER INTO A PRIVATE CONTRACT WITH A HEALTH CARE PROVIDER
THAT CONTAINS A PROVISION UNDER WHICH THE SUBSCRIBER OR ENROLLEE
ACCEPTS RESPONSIBILITY FOR PAYING CHARGES TO THE HEALTH CARE PROVIDER
IF:
(I) THE HEALTH CARE PROVIDER DOES NOT HAVE A CONTRACT
WITH THE SUBSCRIBER'S OR ENROLLEE'S HEALTH MAINTENANCE ORGANIZATION;
(II) THE HEALTH MAINTENANCE ORGANIZATION DID NOT REFER
THE SUBSCRIBER OR ENROLLEE TO THE HEALTH CARE PROVIDER;
(III) THE HEALTH CARE SERVICES PROVIDED ARE NOT EMERGENCY
SERVICES; AND
(IV) BEFORE TREATMENT, THE PATIENT AND HEALTH CARE
PROVIDER SIGN A FORM DEVELOPED BY THE HEALTH EDUCATION AND ADVOCACY
UNIT IN THE CONSUMER PROTECTION DIVISION OF THE OFFICE OF THE ATTORNEY
GENERAL.
(3) THE FORM DESCRIBED IN PARAGRAPH (1)(IV) OF THIS SUBSECTION
SHALL STATE IN PLAIN LANGUAGE THAT:
(I) THE SUBSCRIBER OR ENROLLEE IS ACCEPTING FINANCIAL
RESPONSIBILITY FOR THE HEALTH CARE SERVICES; AND
(II) THE CONDITIONS OF PARAGRAPH (1)(I), (II), AND (III) OF THE
SUBSECTION ARE MET.
(E) THE PROVISIONS OF THIS SECTION AND § 19-710(O) OF THIS SUBTITLE DO
NOT APPLY TO HEALTH CARE SERVICES THAT ARE COVERED BY THE HEALTH
MAINTENANCE ORGANIZATION SOLELY AS A RESULT OF A POINT OF SERVICE
OPTION OF A HEALTH MAINTENANCE ORGANIZATION AS DEFINED IN § 19-719.2 OF
THIS SUBTITLE.
|
|
|
|
|
|
|
|
|
|
- 1636 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
