Chapter 08. Payments to Nonparticipating Providers

“Berenson-Eggers Type of Service Code” has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.

“CPT code” means the Current Procedural Terminology Code maintained and distributed by the American Medical Association, including its codes and modifiers, and codes for anesthesia services.

“Enrollee” has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.

“Evaluation and management services” has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.

“Geographic area” means each geographic area as published by the Centers for Medicare and Medicaid Services.

“HCPCS” means the Healthcare Common Procedure Coding System, a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology and other services such as ambulance services, prosthetic devices, other supplies, and non-physician services that are not covered by CPT codes but are recognized and maintained by the Centers for Medicare and Medicaid Services.

“Health maintenance organization” has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

“Medicare Economic Index” has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.

“Nonparticipating provider” means a provider other than a hospital or trauma physician who is not included on the provider panel of a health maintenance organization.

“Participating provider” means a provider other than a hospital or trauma physician who is included on the provider panel of a health maintenance organization.

“Provider” means a health care practitioner licensed, certified, or otherwise authorized by law to provide health care services.

“Provider panel” has the meaning stated in Insurance Article, §15-112, Annotated Code of Maryland.

“Reference year” means, for services provided in a particular calendar year, the period beginning with July 1 of the second previous calendar year through June 30 of the previous calendar year.

“Similarly licensed provider” has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.

“Trauma physician” has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.

For each type of similarly licensed provider, the rate paid for the CPT code or HCPCS code shall be equal to the total amount allowed for the occurrences of the CPT code or HCPCS code to participating providers who are similarly licensed providers in the same geographic area during the reference year divided by the total number of occurrences paid for the same CPT code or HCPCS code to participating providers who are similarly licensed providers in the same geographic area during the reference year.

For any new CPT code or HCPCS code, the rate paid for the CPT code or HCPCS code shall be equal to 125 percent of the rate paid to a similarly licensed provider in the same geographic area.

Annual rating schedule applicable to the year in which the certification is made is, to the best of that individual's knowledge, information, and belief, compliant with this regulation; and

Individual making the certification has undertaken an adequate inquiry to make the required certification.

125 percent of the fee for the covered evaluation and management service in the annual fee schedule applicable to similarly licensed providers in the same geographic area; or

140 percent of the fee for the covered evaluation and management service paid by Medicare as published by the Centers for Medicare and Medicaid Services as of August 1, 2008, inflated by the four quarter moving average percent change in the Medicare Economic Index from 2008 to the current year.

A list of covered services that qualify as Berenson-Eggers Type of Service Code evaluation and management services; and

The inflation factor applicable for inflating 2008 fees to the current year using four quarter moving average percent change for the previous calendar year second quarter.