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<section article="gin" article_name="Insurance" number="15-1003" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review">
  <level label="a">
    <level label="1">
      <text>In this section the following words have the meanings indicated.</text>
    </level>
    <level label="2">
      <level label="i">
        <text>“Health care practitioner” means a person that is licensed or certified under the Health Occupations Article and reimbursed by a third party payor.</text>
      </level>
      <level label="ii">
        <text>“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.</text>
      </level>
    </level>
    <level label="3">
      <text>“Hospital” has the meaning stated in § 19-301 of the Health - General Article.</text>
    </level>
  </level>
  <level label="b">
    <text>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.</text>
  </level>
  <level label="c">
    <text>The Commissioner shall adopt by regulation a uniform claims form for reimbursement of health care practitioners’ services.</text>
  </level>
  <level label="d">
    <level label="1">
      <text>The Commissioner shall adopt by regulation:</text>
      <level label="i">
        <text>a definition of a clean claim, including:</text>
        <level label="1">
          <text>the essential data elements that must be completed on the uniform claims form; and</text>
        </level>
        <level label="2">
          <text>uniform standards for attachments to the uniform claims form;</text>
        </level>
      </level>
      <level label="ii">
        <text>permissible categories of disputed claims for which additional information may be requested under §§ 15-1004(c) and 15-1005(c) of this subtitle; and</text>
      </level>
      <level label="iii">
        <text>standards for determining when a claim is considered received for reimbursement.</text>
      </level>
    </level>
    <level label="2">
      <text>In adopting the regulations required under paragraph (1)(i) of this subsection, the Commissioner shall consider:</text>
      <level label="i">
        <text>standards for attachments required by the federal Centers for Medicare and Medicaid Services for the Medicare Program;</text>
      </level>
      <level label="ii">
        <text>standards used by insurance carriers, nonprofit health service plans, and health maintenance organizations in the State; and</text>
      </level>
      <level label="iii">
        <text>federal regulations adopted under the Health Insurance Portability and Accountability Act.</text>
      </level>
    </level>
  </level>
</section>
