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<regulation prefix="Regulation" num=".18" citation="COMAR 10.67.04.18" title_num="10" subtitle_num="67" chapter_num="04" heading="Third-Party Liability.">
  <paragraph num="A.">
    <text>An MCO is responsible for the identification of, and collection of, moneys owing from responsible third parties liable for the cost of medical care furnished by the MCO to enrollees.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Upon request from the Department or the U.S. Department of Health and Human Services, an MCO shall convey any information regarding third-party liability to the Department, to the U.S. Department of Health and Human Services, or to another MCO.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The Department shall notify an MCO of any third-party liability identified during the course of eligibility determination.</text>
  </paragraph>
  <paragraph num="D.">
    <text>The MCO shall submit to the Department any new or changed third-party information in an automated format on a monthly basis.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The Department shall provide the MCOs with any new or changed information on a monthly basis in an automated format.</text>
  </paragraph>
  <paragraph num="F.">
    <text>In order to facilitate the Department's and the U.S. Department of Health and Human Services' monitoring of its third-party liability collection activities, an MCO shall:</text>
    <paragraph num="(1)">
      <text>Submit to the Department, on a monthly basis, reports on third-party collections and activities during the month, including but not limited to amounts the MCO has cost-avoided and recovered and current accounts receivable for all third-party liability cases;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Submit to the Department, on a quarterly basis and in a format specified by the Department, amounts the MCO has cost-avoided and recovered and the number of cases the MCO has handled in each case area during the quarter;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Cooperate in site inspections by either the Department or the U.S. Department of Health and Human Services for monitoring purposes; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Submit a detailed report of third-party liability collection activities including, but not limited to, cost avoidance, recovered amounts, and current amounts receivable for cases selected by the Department.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>When both the Department and an MCO have a right of subrogation, they shall coordinate settlement negotiation, ensuring that the funds available are prorated to allow sufficient compensation to settle each party's claim amount.</text>
  </paragraph>
  <paragraph num="H.">
    <text>For insurance coverage identified by an MCO with a retroactive effective date, an MCO shall comply with Insurance Article, §15-1008, Annotated Code of Maryland.</text>
  </paragraph>
  <paragraph num="I.">
    <text>An MCO may not deny a provider’s request for a preauthorization solely because a recipient has, or is thought to have, third-party insurance.</text>
  </paragraph>
  <paragraph num="J.">
    <text>The requirement in §I of this regulation may not apply if an MCO has a process in place to ensure that a claim will not be denied for lack of preauthorization if the claim ultimately becomes the MCOs responsibility for one of the following reasons:</text>
    <paragraph num="(1)">
      <text>The recipient does not have third-party insurance; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The service received is a noncovered service under the third-party insurance.</text>
    </paragraph>
  </paragraph>
  <paragraph num="K.">
    <text>If an MCO identifies another party as being responsible for retroactive denial of reimbursement, the MCO shall:</text>
    <paragraph num="(1)">
      <text>Obtain a written statement from the third-party that includes:</text>
      <paragraph num="(a)">
        <text>The name and address of the third party; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Acknowledgment of responsibility for payment of the denied claim by the third party;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Send this written statement to the provider seeking reimbursement; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Provide this written statement or a summary report to the Department upon request.</text>
    </paragraph>
  </paragraph>
</regulation>