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31.10.11.00.htm 31.10.11.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 10 HEALTH INSURANCE ― GENERAL Chapter 11 Uniform Claims Forms Authority: Health Occupations Article, §1-208; Insurance Article, §2-108, 2-109, and 15-1003―15-1005; Annotated Code of Maryland
31.10.11.01.htm 31.10.11.01. 01 Applicability and Scope.. A. This chapter is applicable to all:. 1) Claims submitted to third-party payors as defined in Regulation .02B(22) of this chapter;. 2) Claims submitted by health care practitioners as defined in Regulation .02B(12) of this chapter;. 3) Claims submitted by hospitals as defined in Health-General Article, §19-301(g) Annotated Code of Maryland; and4) Claims submitted by other persons entitled to reimbursement from a third-party payor who submit c
31.10.11.02.htm 31.10.11.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Applicable standard code set" means the most recent versions, as of the date of service, of the following:a) For services rendered by health care practitioners, the Current Procedural Terminology (CPT) maintained and distributed by the American Medical Association, including its codes and modifiers, and codes for anesthesia services;b) For dental services, t
31.10.11.03.htm 31.10.11.03. 03 Requirements for Use of HCFA Form 1500.. A. Except as provided in Regulation .10 of this chapter, third-party payors shall accept the HCFA Form 1500 and instructions provided by CMS for use of the HCFA 1500 as the sole instrument for filing claims with third-party payors for professional services.B. The requirement set forth in §A of this regulation does not apply to:. 1) Dental services which are billed by dentists using the J512 Form, or its equivalent, and CDT-1 Codes; or
31.10.11.04.htm 31.10.11.04. 04 Requirements for Use of J512 Form.. A. Third-party payors shall accept the J512 Form, or its equivalent, and most recent version of the instructions provided by the American Dental Association CDT-1 for use of the J512 Form, or its equivalent, as the sole instrument for filing claims with third-party payors for dental services.B. A third-party payor may not require a dentist to use any code other than the CDT-1 codes for the initial filing of claims for dental care services.
31.10.11.05.htm 31.10.11.05. 05 Requirements for Use of HCFA Form UB-92.. A. Third-party payors shall accept HCFA Form UB-92, and its successors, and the instructions provided by CMS for use of the HCFA Form UB-92, as the sole instrument for filing claims with third-party payors for hospital and other health-care services.B. Except for parties to a global contract, a third-party payor may not use, and may not require a hospital, or person entitled to reimbursement, to use any code or modifier f
31.10.11.06.htm 31.10.11.06. 06 Requirements for Use of Universal Prescription Drug Claim Form.. Third-party payors shall accept the Universal Prescription Drug Claim Form, or its electronic equivalent, as the sole instrument for filing claims with third-party payors for prescription drugs.
31.10.11.07.htm 31.10.11.07. 07 General Provisions.. A. A third-party payor shall accept a clean claim which is submitted in compliance with these regulations for the processing of the third-party payor's claims.B. A third-party payor is subject to the provisions of Insurance Article, §15-1005, Annotated Code of Maryland.C. If a third party payor delegates its claims processing to another entity, the third-party payor is responsible for a violation by the entity of any regulation under this chapter.
31.10.11.08.htm 31.10.11.08. 08 Essential Data Elements for Clean Claims by Health Care Practitioners or Persons Entitled to Reimbursement.A. In General. To qualify as a clean claim, a claim submitted to a third-party payor by a health care practitioner as provided in Regulation .03 of this chapter, or by a person entitled to reimbursement, shall conform to the applicable standard code set and include the following data elements:1) Subscriber's plan ID number (HCFA Form 1500, field 1a).
31.10.11.09.htm 31.10.11.09. 09 Essential Data Elements for Clean Claims by Hospitals.. A. In General. To qualify as a clean claim, a claim submitted to a third-party payor by a hospital, or person entitled to reimbursement, shall conform to the applicable standard code set and include the following data elements:1) Hospital's, or person entitled to reimbursement's, name, address, and telephone number (HCFA Form UB-92, field 1)2) Patient's control number (HCFA Form UB-92, field 3).
31.10.11.10.htm 31.10.11.10. 10 Attachments to Uniform Claims Forms.. A. 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:1) 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 th
31.10.11.11.htm 31.10.11.11. 11 Additional Information.. A. The following are permissible categories of disputed claims for which third-party payors may request additional information pursuant to Insurance Article, §15-1004(c) and 15-1005(c) Annotated Code of Maryland:1) Except in cases of services rendered in accordance with Health-General Article, §19-701(d) and 19-712.5, Annotated Code of Maryland, the legitimacy, medical necessity, or appropriateness of the health care service, if:
31.10.11.12.htm 31.10.11.12. 12 Receipt of a Claim.. A. Each third-party payor shall:. 1) Date-stamp the claim with the date received, for a written claim; or. 2) Assign to the document a batch number that includes the date received for an electronic claim.. B. Each third-party payor shall maintain a written or electronic record of the date of receipt of a claim.C. Except as provided in §E of this regulation, a claim is presumed to have been received by a third-party payor according to the date of receipt of t
31.10.11.13.htm 31.10.11.13. 13 Disclosure.. A. Third-party payors shall follow the disclosure requirements set forth in Insurance Article, §15-1004(d) Annotated Code of Maryland.B. If a third-party payor uses auto codes to determine whether health care services provided in a hospital emergency facility are "emergency services" as defined in Health-General Article, §19-701(e) Annotated Code of Maryland, the third-party payor shall provide to all contracting health care practitioners or hospitals ren
31.10.11.14.htm 31.10.11.14. 14 Claims Data Filing.. A. Required.. 1) Except as provided in §B(2) of this regulation, twice each calendar year a third-party payor shall submit to the Commissioner a claims data filing that documents the payment and denial practices for claims from health care practitioners, hospitals, and other persons entitled to reimbursement of:a) The third-party payor; and. b) Each entity to which the third-party payor has delegated claims processing.. 2) Each claims data filin
31.10.11.9999.htm 31.10.11.9999. Administrative History. Regulations .01―07 adopted as an emergency provision effective July 22, 1993 (20:16 Md. R. 1274) adopted permanently effective October 25, 1993 (20:21 Md. R. 1653) ―Chapter recodified from COMAR 09.30.56 to COMAR 31.10.11, July 1998 ―. Chapter revised effective September 7, 2001 (28:12 Md. R. 1113) December 11, 2003 (30:24 Md. R. 1747)Regulation .02B amended effective October 1, 2015 (42:15 Md. R. 1019).
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