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PARRIS N. GLENDENING, Governor
Article - Health - General
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Ch. 250
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19-710.1.
(b) (1) In addition to any other provisions of this subtitle, for a covered
service rendered to an enrollee of a health maintenance organization by a health care
provider not under written contract with the health maintenance organization, the
health maintenance organization or its agent:
(i) Shall pay the health care provider within 30 days after the
receipt of a claim in accordance with the applicable provisions of this subtitle; and
(ii) Shall pay the claim submitted by:
1. A hospital at the rate approved by the Health Services
Cost Review Commission;
2. A trauma physician for trauma care rendered to a trauma
patient in a trauma center, at the greater of:
A. 140% of the rate paid by the Medicare program, as
published by the [Health Care Financing Administration] CENTERS FOR MEDICARE
AND MEDICAID SERVICES, for the same covered service, to a similarly licensed
provider; or
B. The rate as of January 1, 2001 that the health
maintenance organization paid in the same geographic area, AS PUBLISHED BY THE
CENTERS FOR MEDICARE AND MEDICAID SERVICES, for the same covered service, to a
similarly licensed provider; and
3. Any other health care provider at the greater of:
A. 125% of the rate the health maintenance organization
pays in the same geographic area, AS PUBLISHED BY THE CENTERS FOR MEDICARE
AND MEDICAID SERVICES, for the same covered service, to a similarly licensed
provider under written contract with the health maintenance organization; or
B. The rate as of January 1, 2000 that the health
maintenance organization paid in the same geographic area, AS PUBLISHED BY THE
CENTERS FOR MEDICARE AND MEDICAID SERVICES, for the same covered service, to a
similarly licensed provider not under written contract with the health maintenance
organization.
(2) A health maintenance organization shall disclose, on request of a
health care provider not under written contract with the health maintenance
organization, the reimbursement rate required under paragraph (1)(ii)2 and 3 of this
subsection.
(3) (i) Subject to subparagraph (ii) of this paragraph, a health
maintenance organization may require a trauma physician not under contract with
the health maintenance organization to submit appropriate adjunct claims
documentation and to include on the uniform claim form a provider number assigned
to the trauma physician by the health maintenance organization.
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- 2005 -
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