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H.B. 305
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VETOES
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(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.
(6) "REIMBURSEMENT" MEANS PAYMENTS MADE TO A HEALTH CARE
PROVIDER BY A CARRIER ON EITHER A FEE-FOR-SERVICE, CAPITATED, OR PREMIUM
BASIS.
(B) THIS SECTION DOES NOT APPLY TO AN ADJUSTMENT TO
REIMBURSEMENT MADE AS PART OF AN ANNUAL CONTRACTED RECONCILIATION OF
A RISK SHARING ARRANGEMENT UNDER AN ADMINISTRATIVE SERVICE PROVIDER
CONTRACT.
(b) (C) (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) (D) Except as provided in subsection (d) (E) of this section, a carrier that
does not comply with the provisions of subsection (b) (C) 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) (E) (1) The provisions of subsection (b)(1) (C)(1) of this section do not
apply if A CARRIER RETROACTIVELY DENIES REIMBURSEMENT TO A HEALTH CARE
PROVIDER BECAUSE;
(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 INFORMATION SUBMITTED
TO THE CARRIER WAS IMPROPERLY CODED AND the carrier has provided to the
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- 4388 -
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