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Martin O'Malley, Governor
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Ch. 452
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(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.
(d) Except as provided in subsection (e) of this section, a carrier that does not
comply with the provisions of subsection (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.
(e) (1) The provisions of subsection (c)(1) of this section do not apply if a
carrier retroactively denies reimbursement to a health care provider because:
(i) the information submitted to the carrier was fraudulent;
(ii) the information submitted to the carrier was improperly
coded and the carrier has provided to the health care provider sufficient information
regarding the coding guidelines used by the carrier at least 30 days prior to the date
the services subject to the retroactive denial were rendered; or
(iii) the claim submitted to the carrier was a duplicate claim; OR
(IV) FOR A CLAIM SUBMITTED TO A MANAGED CARE
ORGANIZATION, THE CLAIM WAS FOR SERVICES PROVIDED TO A MARYLAND
MEDICAL ASSISTANCE PROGRAM RECIPIENT DURING A TIME PERIOD FOR
WHICH THE PROGRAM HAS PERMANENTLY RETRACTED THE CAPITATION
PAYMENT FOR THE PROGRAM RECIPIENT FROM THE MANAGED CARE
ORGANIZATION.
(2) Information submitted to the carrier may be considered to be
improperly coded under paragraph (1) of this subsection if the information submitted
to the carrier by the health care provider:
(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.
(f) If a carrier retroactively denies reimbursement for services as a result of
coordination of benefits under provisions of subsection (c)(1)(i) of this section, the
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- 2695 -
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