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S.B. 800
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VETOES
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(III) AFTER APPROVAL BY THE COMMISSIONER:
1. WRITTEN NOTICE OF ANY CHANGE IS RECEIVED BY THE
PROVIDER AT LEAST 60 DAYS .BEFORE THE CHANGE TAKES EFFECT; AND
2. THE MANUAL OR OTHER DOCUMENT THAT SETS FORTH
THE CLAIMS FILING PROCEDURES IS UPDATED TO REFLECT THE CHANCE AND IS
SENT TO THE PROVIDER AT LEAST 60 DAYS BEFORE THE CHANGE TAKES EFFECT.
[(d)] (E) (1) If necessary to determine eligibility for benefits or to determine
coverage, an insurer, [or] nonprofit health service plan, OR HEALTH MAINTENANCE
ORGANIZATION may obtain additional information from its insured, MEMBER, OR
SUBSCRIBER, the [insured's] employer OF THE INSURED, MEMBER OR SUBSCRIBER,
or any other nonprovider third party.
(2) If obtaining additional information results in a delay in paying a
claim, the insurer, [or] nonprofit health service plan, OR HEALTH MAINTENANCE
ORGANIZATION shall pay interest in accordance with the provisions of § 15-1005(d) §
15-1005(F) of this subtitle.
[(e)] (F) The Commissioner may impose a penalty not exceeding [$500] $5,000
on an insurer, [or] nonprofit health service plan, OR HEALTH MAINTENANCE
ORGANIZATION that violates this section.
15-1005.
(a) [This section does not apply when there is a good faith dispute about the
legitimacy of a claim or the appropriate amount of reimbursement.] IN THIS SECTION,
"CLEAN CLAIM" MEANS A CLAIM FOR REIMBURSEMENT, AS DEFINED IN
REGULATIONS ADOPTED BY THE COMMISSIONER UNDER § 15-1004 § 15-1003 OF THIS
SUBTITLE.
(b) To the extent consistent with the Employee Retirement Income Security
Act of 1974 (ERISA), 29 U.S.C. 1001, et seq., this section applies to an insurer,
nonprofit health service plan, or health maintenance organization that acts as a third
party administrator.
(c) [Within 30 days after] AFTER receipt of a CLEAN claim for reimbursement
from a person entitled to reimbursement under § 15-701(a) of this title or from a
hospital or related institution, as those terms are defined in § 19-301 of the Health -
General Article, an insurer, nonprofit health service plan, or health maintenance
organization shall:
(1) WITHIN 30 DAYS, pay the claim in accordance with this section; or
(2) WITHIN 15 DAYS, send a notice of receipt and status of the claim that
states:
(i) that the insurer, nonprofit health service plan, or health
maintenance organization refuses to reimburse all or part of the claim and the reason
for the refusal;
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- 4164 -
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