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<section article="gin" article_name="Insurance" number="15-1004" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review">
  <level label="a">
    <text>For services rendered by a person entitled to reimbursement under § 15–701(a) of this title or by a hospital, as defined in § 19–301 of the Health – General Article, an insurer, nonprofit health service plan, or health maintenance organization:</text>
    <level label="1">
      <text>shall accept the uniform claims form and any attachments approved or adopted by the Commissioner under § 15–1003 of this subtitle:</text>
      <level label="i">
        <text>as a properly filed claim with all necessary documentation; and</text>
      </level>
      <level label="ii">
        <text>as the sole instrument for reimbursement; and</text>
      </level>
    </level>
    <level label="2">
      <text>may not impose as a condition of reimbursement a requirement to:</text>
      <level label="i">
        <text>modify the uniform claims form or its content; or</text>
      </level>
      <level label="ii">
        <text>submit additional claims forms.</text>
      </level>
    </level>
  </level>
  <level label="b">
    <level label="1">
      <text>A uniform claims form submitted under this section shall be completed properly and may be submitted by electronic transfer.</text>
    </level>
    <level label="2">
      <text>If the health care practitioner rendering the service is a certified registered nurse anesthetist or certified nurse midwife, the uniform claims form shall include identification modifiers for the certified registered nurse anesthetist or certified nurse midwife that indicate whether the service is provided with or without medical direction by a physician.</text>
    </level>
  </level>
  <level label="c">
    <text>In accordance with §§ 15–1003(d)(1)(ii) and 15–1005(c) of this subtitle, if the legitimacy or appropriateness of a health care service is disputed, an insurer, nonprofit health service plan, or health maintenance organization may request additional medical information that describes and summarizes the diagnosis, treatment, and services rendered to the insured.</text>
  </level>
  <level label="d">
    <level label="1">
      <text>Insurers, nonprofit health service plans, and health maintenance organizations shall provide and update, as appropriate, all contracting providers and any other provider on request, with a manual or other document that sets forth the claims filing procedures, including:</text>
      <level label="i">
        <text>the address where the claims should be sent for processing;</text>
      </level>
      <level label="ii">
        <text>the telephone number at which providers’ questions and concerns regarding claims may be addressed;</text>
      </level>
      <level label="iii">
        <text>the name, address, and telephone number of any entity to which the insurer, nonprofit health service plan, or health maintenance organization has delegated the claims payment function, if applicable; and</text>
      </level>
      <level label="iv">
        <text>the address and telephone number of any separate claims processing center for specific types of applicable services.</text>
      </level>
    </level>
    <level label="2">
      <text>If an insurer, nonprofit health service plan, or health maintenance organization has delegated its claims processing function to a third party, the delegation agreement:</text>
      <level label="i">
        <text>shall require the claims processing entity to comply with the requirements of this subtitle; and</text>
      </level>
      <level label="ii">
        <text>may not be construed to limit the responsibility of the insurer, nonprofit health service plan, or health maintenance organization to comply with the requirements of this subtitle.</text>
      </level>
    </level>
  </level>
  <level label="e">
    <level label="1">
      <text>If necessary to determine eligibility for benefits or to determine coverage, an insurer, nonprofit health service plan, or health maintenance organization may obtain additional information from its insured, member, or subscriber, the employer of the insured, member or subscriber, or any other nonprovider third party.</text>
    </level>
    <level label="2">
      <text>If obtaining additional information results in a delay in paying a claim, the insurer, nonprofit health service plan, or health maintenance organization shall pay interest in accordance with the provisions of § 15–1005(g) of this subtitle.</text>
    </level>
  </level>
  <level label="f">
    <text>The Commissioner may impose a penalty not exceeding $5,000 on an insurer, nonprofit health service plan, or health maintenance organization that violates this section.</text>
  </level>
</section>
