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S.B. 275
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VETOES
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(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) If a carrier retroactively denies reimbursement for services as a result of
coordination of benefits under provisions of subsection (b)(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.
Article - Health - General
19-706.
(o) The provisions of [§ 15-1008] §§ 15-1008 AND 15-1009 of the Insurance
Article [shall] apply to health maintenance organizations.
Article - Insurance
15-1009.
(A) IN THIS SECTION, "CARRIER" MEANS:
(1) AN INSURER;
(2) A NONPROFIT HEALTH SERVICE PLAN;
(3) A HEALTH MAINTENANCE ORGANIZATION;
(4) A DENTAL PLAN ORGANIZATION; OR
(5) ANY OTHER PERSON THAT PROVIDES HEALTH BENEFIT PLANS
SUBJECT TO REGULATION BY THE STATE.
(F) (B) IF A COURSE OF TREATMENT HEALTH CARE SERVICE FOR A PATIENT
HAS BEEN PREAUTHORIZED OR APPROVED BY A CARRIER OR THE CARRIER'S
PRIVATE REVIEW AGENT. THE CARRIER MAY NOT DENY REIMBURSEMENT TO A
HEALTH CARE PROVIDER FOR THE PREAUTHORIZED OR APPROVED SERVICES
SERVICE DELIVERED TO THAT PATIENT UNLESS:
(1) THE INFORMATION SUBMITTED TO THE CARRIER REGARDING THE
SERVICES SERVICE TO BE DELIVERED TO THE PATIENT WAS FRAUDULENT OR
INTENTIONALLY MISREPRESENTATIVE OR;
(2) CRITICAL INFORMATION REQUESTED BY THE CARRIER REGARDING
SERVICES THE SERVICE TO BE DELIVERED TO THE PATIENT WAS OMITTED SUCH
THAT THE CARRIER'S DETERMINATION WOULD HAVE BEEN DIFFERENT HAD IT
KNOWN THE CRITICAL INFORMATION; OR
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- 3814 -
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