<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".04" citation="COMAR 31.04.15.04" title_num="31" subtitle_num="04" chapter_num="15" heading="Procedures and Requirements.">
  <paragraph num="A.">
    <text>Antifraud Plan.</text>
    <paragraph num="(1)">
      <text>This section does not apply to an insurer that has filed an antifraud plan with the Administration, and the plan has been approved by the Commissioner.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>An insurer authorized to write insurance business that has in force policies or certificates of insurance in this State shall institute, implement, and maintain an insurance antifraud plan.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>An insurer shall submit an antifraud plan within 90 days of the insurer issuing or delivering a policy or certificate of insurance in the State.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Contents of Antifraud Plan. An antifraud plan shall:</text>
    <paragraph num="(1)">
      <text>Contain provisions for educating and training an insurer's employees in the detection of insurance fraud;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Provide for methods and procedures concerning the investigation of suspicious claims; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Apply to but not be limited to:</text>
      <paragraph num="(a)">
        <text>Claims fraud,</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Application fraud,</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Insurance producer fraud,</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Third-party administrator fraud, and</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Internal fraud.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Amendments to Antifraud Plans. Within 30 days after modifying or amending an antifraud plan, an insurer shall:</text>
    <paragraph num="(1)">
      <text>Notify the Commissioner in writing; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Provide a copy of the revised antifraud plan showing the amendments.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Approval of Antifraud Plans and Amendments.</text>
    <paragraph num="(1)">
      <text>The Commissioner shall review each insurer's antifraud plan and any subsequent amendments to determine compliance with:</text>
      <paragraph num="(a)">
        <text>The requirements of Insurance Article, §27-803, Annotated Code of Maryland; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>This chapter.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>If the Commissioner has not disapproved an antifraud plan or amendment within 30 days of its filing, the plan shall be deemed approved.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Under §D(1) of this regulation, if the Commissioner determines that an insurer's antifraud plan and any subsequent amendment is not in compliance, the Commissioner shall disapprove the plan or amendment and send a written notice of disapproval with the reasons for disapproval to the insurer.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>If the insurer's antifraud plan is disapproved by the Commissioner, the insurer shall submit a new plan to the Commissioner within 60 days after the date the plan was disapproved.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>This regulation does not apply to third party administrators (TPAs) that only participate in federal programs and are therefore required to file a federal antifraud plan provided that:</text>
    <paragraph num="(1)">
      <text>Such a federal antifraud plan has been filed with the Centers for Medicare &amp; Medicaid Services;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The TPA provides the federal antifraud plan at the Commissioner's request; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The TPA files a written attestation stating:</text>
      <paragraph num="(a)">
        <text>The name of the TPA;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The name and title of the employee attesting who has authority to bind the TPA;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>That the TPA is required to file an antifraud plan with the federal government; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>The date the TPA filed the antifraud plan with the federal government.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>