<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".12" citation="COMAR 10.09.41.12" title_num="10" subtitle_num="09" chapter_num="41" heading="Fraud, Liens, Recovery, and Reimbursement.">
  <paragraph num="A.">
    <text>The provisions of COMAR 10.09.24.14 concerning fraud apply to this chapter.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The Department shall make a claim against income or resources, or both, of a recipient for benefits correctly paid, or to be paid, under the circumstances specified in COMAR 10.09.24.15A-1.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The Department may impose a lien on the property of a recipient under the circumstances specified in COMAR 10.09.24.15A-2(1).</text>
  </paragraph>
  <paragraph num="D.">
    <text>The Department shall seek recovery of Medical Assistance benefits correctly paid as provided in COMAR 10.09.24.15A-3.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The Department shall accept reimbursement if voluntarily offered by a current or former recipient or by someone acting on behalf of the current or former recipient.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Extended Benefits Pending a Hearing Decision.</text>
    <paragraph num="(1)">
      <text>The Department shall refer for reimbursement consideration all cases in which:</text>
      <paragraph num="(a)">
        <text>A recipient received extended benefits pending a hearing and decision by the hearing officer; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The hearing officer affirmed the decision of the Department that was the subject of the appeal.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The Department:</text>
      <paragraph num="(a)">
        <text>Shall institute procedures to recover the cost of any expenditures made on behalf of a recipient in cases identified in §F(1) of this regulation; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>May not apply §F(2)(a) of this regulation to an individual who requested a hearing and extended benefits based on a bona fide belief that the adverse action was erroneous.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>The Department shall refer for investigation and other appropriate action all cases in which a recipient has received coverage erroneously as a result of the action or inaction of the recipient, representative, or individual acting responsibly for the recipient.</text>
  </paragraph>
  <paragraph num="H.">
    <text>The Department shall investigate and take appropriate action in all cases in which eligibility has been incorrectly established as a result of the action or inaction of a recipient, representative, or individual acting responsibly for the recipient.</text>
  </paragraph>
  <paragraph num="I.">
    <text>Providers.</text>
    <paragraph num="(1)">
      <text>If a recipient has ESI or other coverage, or if any other individual is obligated, either legally or contractually, to pay for, or to reimburse the recipient for, services covered by this chapter, a provider of covered services shall seek payment from that source before submitting a claim to the Medical Assistance Program.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>If an insurance carrier rejects the provider's claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Medical Assistance Program, which shall be accompanied by a copy of the insurance carrier's notice or remittance advice.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>If payment is made by both the Medical Assistance Program and the insurance or other source for the same service, the provider shall refund to the Department, within 60 days of receipt, the amount paid by the Medical Assistance Program or the insurance or other source, whichever is less.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>A provider shall reimburse the Department for any overpayment.</text>
    </paragraph>
  </paragraph>
  <paragraph num="J.">
    <text>Recipients. A recipient shall assist and cooperate with the Department's efforts to collect available health insurance benefits and other third party payments by:</text>
    <paragraph num="(1)">
      <text>Completing a form designated by the Department to report all pertinent information to assist the Department in seeking reimbursement for services provided;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Notifying the Department within 10 days if medical treatment has been provided as a result of any accident or other occurrence in which a third party may be liable for health care services provided to the recipient; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Providing to the Department, as set forth in §J(2) of this regulation, the information required under such circumstances pursuant to COMAR 10.09.24.12 and Regulation .09B(1)(d) of this chapter.</text>
    </paragraph>
  </paragraph>
</regulation>