|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S.B. 275
|
|
|
|
|
|
PARRIS N. GLENDENING, Governor
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(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 48-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.
(c) 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
the health care provider, withholding future reimbursement, or in any other manner
affecting the future reimbursement to the health care provider.
(d) (1) The provisions of subsection (b)(1) of this section do not apply if:
(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 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.
(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:
|
|
|
|
|
|
|
|
|
|
- 3813 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
