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<section article="gin" article_name="Insurance" number="15-1009" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review">
  <level label="a">
    <text>In this section, “carrier” means:</text>
    <level label="1">
      <text>an insurer;</text>
    </level>
    <level label="2">
      <text>a nonprofit health service plan;</text>
    </level>
    <level label="3">
      <text>a health maintenance organization;</text>
    </level>
    <level label="4">
      <text>a dental plan organization; or</text>
    </level>
    <level label="5">
      <text>any other person that provides health benefit plans subject to regulation by the State.</text>
    </level>
  </level>
  <level label="b">
    <text>If a health care service for a patient has been preauthorized or approved by a carrier or the carrier’s private review agent, the carrier may not deny reimbursement to a health care provider for the preauthorized or approved service delivered to that patient unless:</text>
    <level label="1">
      <text>the information submitted to the carrier regarding the service to be delivered to the patient was fraudulent or intentionally misrepresentative;</text>
    </level>
    <level label="2">
      <text>critical information requested by the carrier regarding the service to be delivered to the patient was omitted such that the carrier’s determination would have been different had it known the critical information;</text>
    </level>
    <level label="3">
      <text>a planned course of treatment for the patient that was approved by the carrier was not substantially followed by the health care provider; or</text>
    </level>
    <level label="4">
      <text>on the date the preauthorized or approved service was delivered:</text>
      <level label="i">
        <text>the patient was not covered by the carrier;</text>
      </level>
      <level label="ii">
        <text>the carrier maintained an automated eligibility verification system that was available to the contracting provider by telephone or via the Internet; and</text>
      </level>
      <level label="iii">
        <text>according to the verification system, the patient was not covered by the carrier.</text>
      </level>
    </level>
  </level>
  <level label="c">
    <text>Notwithstanding subsection (b) of this section, a carrier may suspend review of a claim for reimbursement of a preauthorized or approved health care service if:</text>
    <level label="1">
      <text>the patient is in the second or third month of a grace period under 45 C.F.R. § 156.270(d);</text>
    </level>
    <level label="2">
      <text>the carrier maintains an automated eligibility verification system that was available to the health care provider by telephone or via the Internet at the time the health care service was provided;</text>
    </level>
    <level label="3">
      <text>according to the verification system, the provider is informed that:</text>
      <level label="i">
        <text>the patient is in the second or third month of a grace period and review of a claim for reimbursement may be suspended; and</text>
      </level>
      <level label="ii">
        <text>a carrier is not prohibited from denying a claim for reimbursement of a suspended claim; and</text>
      </level>
    </level>
    <level label="4">
      <text>the carrier complies with the notice and claim payment requirements under § 15–1005 of this subtitle.</text>
    </level>
  </level>
  <level label="d">
    <text>A carrier shall pay a claim for a preauthorized or approved covered health care service in accordance with §§ 15–1005 and 15–1008 of this subtitle.</text>
  </level>
</section>
