|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2000 LAWS OF MARYLAND
|
|
|
|
|
|
Ch. 355
|
|
|
|
|
|
|
|
|
|
(ii) a nonprofit health service plan;
(iii) a health maintenance organization;
(iv) a dental plan organisation; 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;
(b) (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 the claim submitted 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.
(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) Except as provided in subsection (d) of this section, a carrier that does not
comply with the provisions of subsection (b) 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
|
|
|
|
|
|
|
|
|
|
- 2040 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
