A third-party payor may require a health care practitioner, hospital, or person entitled to reimbursement to include any of the following attachments to a HCFA Form UB-92 or HCFA Form 1500, respectively, for a claim to qualify as a clean claim: A referral or consultant treatment plan submitted by the specialist, if the claim is for specialty services under an HMO plan or in-network point-of-service plan, unless the third-party payor requires the provider of primary care services to submit directly to it the referral or consultant treatment plan for specialty services; An explanation of benefits statement from the primary payor to the secondary payor, unless an electronic remittance notice has been sent by the primary payor to the secondary payor; A Medicare remittance notice, if the claim involves Medicare as a primary payor and the third-party payor provides evidence that it does not have a crossover agreement to accept an electronic remittance notice; A description of the procedure or service, which may include the medical record, if a procedure or service rendered has no corresponding Current Procedural Terminology (CPT) or HCPCS code, or additional description information relating to a CDT code;; Operative notes, if the claim is for multiple surgeries, or includes modifier 22, 58, 62, 66, 78, 80, 81, or 82; Anesthesia records documenting the time spent on the service, if the claim for anesthesia services rendered includes modifiers P4 or P5; Documents referenced as contractual requirements in the global contract, if there is a global contract between a third-party payor and a health care practitioner, hospital, or person entitled to reimbursement; An ambulance trip report, if the claim is for ambulance services submitted by an ambulance company licensed by the Maryland Institute for Emergency Medical Services Systems; Office visit notes, if the claim includes modifier 21 or 22; Information related to the audit as specified in writing by the third-party payor, if the third-party payor's audit of the health care practitioner, hospital, or person entitled to reimbursement demonstrated a pattern of fraud, improper billing, or improper coding; Admitting notes, except in the case of services rendered in accordance with Health-General Article, §§19-701(d) and 19-712.5, Annotated Code of Maryland, if the claim is for inpatient services provided outside of the time or scope of the authorization; Physician notes, except in the case of services rendered in accordance with Health-General Article, §§19-701(d) and 19-712.5, Annotated Code of Maryland, if the claim for services provided is outside of the time or scope of the authorization, or when there is an authorization in dispute; Itemized bills, except in the case of services rendered in accordance with Health-General Article, §§19-701(d) and 19-712.5, Annotated Code of Maryland, if the claim is for services: Rendered in a hospital and the hospital claim has no prior authorization for admission, or Inconsistent with a third-party payor's concurrent review determination rendered before the delivery of services, regarding the medical necessity of the service; Adjunct claims documentation pursuant to Health-General Article, §19-710.1(b)(3), Annotated Code of Maryland; A treatment plan from a child’s health care practitioner that includes one or more specific treatment goals, if the claim is for habilitative services for a child diagnosed with autism or autism spectrum disorder. In its manual, or other document that sets forth the claim filing procedures pursuant to Insurance Article, §15-1004(d), Annotated Code of Maryland, a third-party payor shall: List the attachments to an HCFA Form UB-92 or HCFA Form 1500 that it may require under §A of this regulation for a claim to qualify as a clean claim; and Describe the circumstances under which each attachment may be required. A third-party payor may accept any additional attachments with the HCFA Form 1500 or HCFA Form UB-92.