Skip to Main Content
<< Back | Return to Main COMAR Search Page

8 records match your request.

FileAbstract
31.12.08.00.htm 31.12.08.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 12 HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS Chapter 08 Payments to Nonparticipating Providers Authority: Health General Article, §19-710.1, Annotated Code of Maryland
31.12.08.01.htm 31.12.08.01. 01 Applicability.. This chapter applies to covered services paid by health maintenance organizations to nonparticipating providers for services provided on or after January 1, 2010.
31.12.08.02.htm 31.12.08.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Berenson-Eggers Type of Service Code" has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.2) "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.3) "Enrollee" has the meaning stated in Health-Gen
31.12.08.03.htm 31.12.08.03. 03 Payment to Nonparticipating Providers.. A. A health maintenance organization shall calculate the amount owed to a nonparticipating provider for covered evaluation and management services provided to an enrollee in accordance with Regulation .05 of this chapter.B. A health maintenance organization shall calculate the amount owed to a nonparticipating provider for covered services other than evaluation and management services provided to an enrollee in accord
31.12.08.04.htm 31.12.08.04. 04 Annual Rate Schedule.. A. Each year, beginning with January 1, 2010, each health maintenance organization shall develop an annual rate schedule for each geographic area.B. The annual rate schedule required by §A of this regulation shall include a rate for each occurrence of a CPT code or HCPCS code that describes covered services for each type of similarly licensed provider in the same geographic area derived in accordance with the formula specified in §C of this regulation.
31.12.08.05.htm 31.12.08.05. 05 Evaluation and Management Services.. A. If a nonparticipating provider submits a claim to a health maintenance organization for a covered evaluation and management service, the health maintenance organization shall pay the nonparticipating provider, less any applicable copayment, coinsurance or deductible amount, an amount not less than the greater of:1) 125 percent of the fee for the covered evaluation and management service in the annual fee schedule applicable to similarl
31.12.08.06.htm 31.12.08.06. 06 Other Covered Services.. If a nonparticipating provider submits a claim to a health maintenance organization for a covered service other than a covered evaluation and management service, the health maintenance organization shall pay the nonparticipating provider, less any applicable copayment, coinsurance or deductible amount, an amount not less than 125 percent of the rate for the covered service in the annual rate schedule applicable to similarly licensed providers in
31.12.08.9999.htm 31.12.08.9999. Administrative History Effective date:. Regulations .01―06 adopted as an emergency provision effective January 1, 2010 (37:4 Md. R. 337) adopted permanently effective March 8, 2010 (37:5 Md. R. 433)
<< Back | Return to Main COMAR Search Page