§ 15-1005. Prompt payment of claims for reimbursement
West's Annotated Code of MarylandInsuranceEffective: May 18, 2021 to May 17, 2025
Effective: May 18, 2021 to May 17, 2025
MD Code, Insurance, § 15-1005
§ 15-1005. Prompt payment of claims for reimbursement
<Section effective until May 18, 2025. See, also, section 15-1005 effective May 18, 2025.>
(a) In this section, “clean claim” means a claim for reimbursement, as defined in regulations adopted by the Commissioner under § 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) Except as provided in § 15-1315 of this title and subsection (i) of this section, within 30 days after receipt of a 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:
(ii) that, in accordance with § 15-1003(d)(1)(ii) of this subtitle, the legitimacy of the claim or the appropriate amount of reimbursement is in dispute and additional information is necessary to determine if all or part of the claim will be reimbursed and what specific additional information is necessary; or
(d)(1)(i) In this subsection, “credit card” means a credit, debit, prepaid, or stored-value card used to make a payment through a private card network.
(2) An insurer, a nonprofit health service plan, or a health maintenance organization may pay a claim under subsection (c) of this section, or a portion of a claim under subsection (f) of this section, using a credit card or an electronic funds transfer payment method that imposes on the provider a fee or similar charge to process the payment if:
(3) If a provider participates on a provider panel of an insurer, a nonprofit health service plan, or a health maintenance organization, the acceptance by the provider or the provider's designee of a payment method offered under paragraph (2)(ii) of this subsection or elected under paragraph (2)(iii) of this subsection shall apply to all claims paid for by the insurer, nonprofit health service plan, or health maintenance organization unless otherwise notified by the provider or the provider's designee.
(e)(1) An insurer, nonprofit health service plan, or health maintenance organization shall permit a provider a minimum of 180 days from the date a covered service is rendered to submit a claim for reimbursement for the service.
(2) If an insurer, nonprofit health service plan, or health maintenance organization wholly or partially denies a claim for reimbursement, the insurer, nonprofit health service plan, or health maintenance organization shall permit a provider a minimum of 90 working days after the date of denial of the claim to appeal the denial.
(3) If an insurer, nonprofit health service plan, or health maintenance organization erroneously denies a provider's claim for reimbursement submitted within the time period specified in paragraph (1) of this subsection because of a claims processing error, and the provider notifies the insurer, nonprofit health service plan, or health maintenance organization of the potential error within 1 year of the claim denial, the insurer, nonprofit health service plan, or health maintenance organization, on discovery of the error, shall reprocess the provider's claim without the necessity for the provider to resubmit the claim, and without regard to timely submission deadlines.
(f)(1) If an insurer, nonprofit health service plan, or health maintenance organization provides notice under subsection (c)(2)(i) of this section, the insurer, nonprofit health service plan, or health maintenance organization shall mail or otherwise transmit payment for any undisputed portion of the claim within 30 days of receipt of the claim, in accordance with this section.
(3) If an insurer, nonprofit health service plan, or health maintenance organization provides notice under subsection (c)(2)(iii) of this section, the insurer, nonprofit health service plan, or health maintenance organization shall comply with subsection (c)(1) or (2)(i) of this section within 30 days after receipt of the requested additional information.
(g)(1) If an insurer, nonprofit health service plan, health maintenance organization, or administrative services organization that administers the delivery system for specialty mental health services established under § 15-103(b)(21) of the Health--General Article fails to pay a clean claim for reimbursement or otherwise violates any provision of this section, the insurer, nonprofit health service plan, health maintenance organization, or administrative services organization shall pay interest on the amount of the claim that remains unpaid 30 days after receipt of the initial clean claim for reimbursement at the monthly rate of:
(h) An insurer, nonprofit health service plan, health maintenance organization, or administrative services organization that administers the delivery system for specialty mental health services established under § 15-103(b)(21) of the Health--General Article that violates a provision of this section is subject to:
(i)(1) An insurer, a nonprofit health service plan, or a health maintenance organization may suspend review of a claim for reimbursement for a preauthorized or approved health care service if the insurer, nonprofit health service plan, or health maintenance organization sends written notice within 30 days after receipt of the claim that informs the person filing the claim, that:
(j) An administrative services organization that administers the delivery system for specialty mental health services established under § 15-103(b)(21) of the Health--General Article is subject to the provisions of Title 2, Subtitle 2 of this article in connection with any investigation or examination of potential violations of this section.
Credits
Added by Acts 1997, c. 35, § 2, eff. Oct. 1, 1997. Amended by Acts 1997, c. 590, § 1, eff. Oct. 1, 1997; Acts 1999, c. 472, § 1, eff. Oct. 1, 1999; Acts 2000, c. 410, § 1, eff. June 1, 2000; Acts 2001, c. 406, § 1, eff. Oct. 1, 2001; Acts 2004, c. 155, § 1, eff. June 1, 2004; Acts 2005, c. 276, § 1, eff. Oct. 1, 2005; Acts 2009, c. 66, § 1, eff. Oct. 1, 2009; Acts 2009, c. 67, § 1, eff. Oct. 1, 2009; Acts 2013, c. 368, § 2, eff. Jan. 1, 2014; Acts 2014, c. 23, § 1, eff. July 1, 2014; Acts 2016, c. 109, § 1, eff. Oct. 1, 2016; Acts 2021, c. 151, § 1, eff. May 18, 2021; Acts 2021, c. 152, § 1, eff. May 18, 2021.
Formerly Art. 48A, §§ 354Z, 470U, 477AA.
MD Code, Insurance, § 15-1005, MD INSURANCE § 15-1005
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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