Md. Code, Insurance § 15-1003
This is the official text of Md. Code, Insurance § 15-1003, part of Maryland’s Code, Insurance — regulates insurance companies and the policies they sell.
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§15–1003.
Official statutory text
(a) (1) In this section the following words have the meanings indicated.
(2) (i) “Health care practitioner” means a person that is licensed or certified under the Health Occupations Article and reimbursed by a third party payor.
(ii) “Health care practitioner” does not include a physician or other person licensed or certified under this article when the physician or other person is rendering care to a member or subscriber of a health maintenance organization and is compensated by the health maintenance organization for that care on a salaried or capitated basis.
(3) “Hospital” has the meaning stated in § 19-301 of the Health - General Article.
(b) The Commissioner shall adopt by regulation as the uniform claims form for reimbursement of hospital services in the State the uniform claims form adopted by the National Uniform Billing Committee and approved by the Centers for Medicare and Medicaid Services for Hospital Payments under Title XVIII of the Social Security Act.
(c) The Commissioner shall adopt by regulation a uniform claims form for reimbursement of health care practitioners’ services.
(d) (1) The Commissioner shall adopt by regulation:
(i) a definition of a clean claim, including:
1. the essential data elements that must be completed on the uniform claims form; and
2. uniform standards for attachments to the uniform claims form;
(ii) permissible categories of disputed claims for which additional information may be requested under §§ 15-1004(c) and 15-1005(c) of this subtitle; and
(iii) standards for determining when a claim is considered received for reimbursement.
(2) In adopting the regulations required under paragraph (1)(i) of this subsection, the Commissioner shall consider:
(i) standards for attachments required by the federal Centers for Medicare and Medicaid Services for the Medicare Program;
(ii) standards used by insurance carriers, nonprofit health service plans, and health maintenance organizations in the State; and
(iii) federal regulations adopted under the Health Insurance Portability and Accountability Act.
(2) (i) “Health care practitioner” means a person that is licensed or certified under the Health Occupations Article and reimbursed by a third party payor.
(ii) “Health care practitioner” does not include a physician or other person licensed or certified under this article when the physician or other person is rendering care to a member or subscriber of a health maintenance organization and is compensated by the health maintenance organization for that care on a salaried or capitated basis.
(3) “Hospital” has the meaning stated in § 19-301 of the Health - General Article.
(b) The Commissioner shall adopt by regulation as the uniform claims form for reimbursement of hospital services in the State the uniform claims form adopted by the National Uniform Billing Committee and approved by the Centers for Medicare and Medicaid Services for Hospital Payments under Title XVIII of the Social Security Act.
(c) The Commissioner shall adopt by regulation a uniform claims form for reimbursement of health care practitioners’ services.
(d) (1) The Commissioner shall adopt by regulation:
(i) a definition of a clean claim, including:
1. the essential data elements that must be completed on the uniform claims form; and
2. uniform standards for attachments to the uniform claims form;
(ii) permissible categories of disputed claims for which additional information may be requested under §§ 15-1004(c) and 15-1005(c) of this subtitle; and
(iii) standards for determining when a claim is considered received for reimbursement.
(2) In adopting the regulations required under paragraph (1)(i) of this subsection, the Commissioner shall consider:
(i) standards for attachments required by the federal Centers for Medicare and Medicaid Services for the Medicare Program;
(ii) standards used by insurance carriers, nonprofit health service plans, and health maintenance organizations in the State; and
(iii) federal regulations adopted under the Health Insurance Portability and Accountability Act.
Status: in_force · Read it on the official government site
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