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Ch. 452
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2007 Laws of Maryland
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(V) A MANAGED CARE ORGANIZATION, AS DEFINED IN §
15-101 OF THE HEALTH - GENERAL ARTICLE; OR
[(v)] (VI) any other person that provides health benefit plans
subject to regulation by the State.
(3) "Code" means:
(i) the applicable current procedural terminology (CPT) code, as
adopted by the American Medical Association;
(ii) if for a dental service, the applicable code adopted by the
- American Dental Association; or
(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.
(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.
(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 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 health care provider.
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- 2694 -
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