10.07.01.16

.16 Protection of Patients — Patient Liability.

A. Charges for any days disallowed as a result of retrospective review by the agent or by a payer conducting utilization review under these regulations shall be deducted from the gross charges in the bill to the patient as a contractual allowance unless the patient refuses or has refused to leave the hospital when it is medically appropriate to do so, and the disallowed days occur:

(1) After the hospital has notified the patient in writing of the potential disallowance; or

(2) As a direct result of the noncompliance by the patient to treatment or hospital regulations.

B. If a bill is generated before the receipt of the results of retrospective review, a subsequent adjustment to the bill, if required under § A, above, shall be issued by the hospital. The final bill shall demonstrate all procedures, services, or days of care found to be inappropriate.

C. In cases when a form of review other than retrospective review was performed, each patient bill generated by the hospital shall clearly demonstrate all procedures, services, or days of care which have been found to be inappropriate or have been disallowed by the hospital's utilization review agent or any other reviewer or payer conducting utilization review.

D. The utilization review agent shall be responsible for establishing a process by which physicians and patients may request clarification and reconsideration of review decisions. These clarifications or reconsiderations shall be carried out in a timely fashion, and patients shall be granted full access to any medical records maintained by the agent pertaining to their care to the extent permitted under Health-General Article, § 4-302, Annotated Code of Maryland.