31.04.15.04

.04 Procedures and Requirements.

A. Antifraud Plan.

(1) This section does not apply to an insurer that has filed an antifraud plan with the Administration, and the plan has been approved by the Commissioner.

(2) An insurer authorized to write insurance business that has in force policies or certificates of insurance in this State shall institute, implement, and maintain an insurance antifraud plan.

(3) An insurer shall submit an antifraud plan within 90 days of the insurer issuing or delivering a policy or certificate of insurance in the State.

B. Contents of Antifraud Plan. An antifraud plan shall:

(1) Contain provisions for educating and training an insurer's employees in the detection of insurance fraud;

(2) Provide for methods and procedures concerning the investigation of suspicious claims; and

(3) Apply to but not be limited to:

(a) Claims fraud,

(b) Application fraud,

(c) Insurance producer fraud,

(d) Third-party administrator fraud, and

(e) Internal fraud.

C. Amendments to Antifraud Plans. Within 30 days after modifying or amending an antifraud plan, an insurer shall:

(1) Notify the Commissioner in writing; and

(2) Provide a copy of the revised antifraud plan showing the amendments.

D. Approval of Antifraud Plans and Amendments.

(1) The Commissioner shall review each insurer's antifraud plan and any subsequent amendments to determine compliance with:

(a) The requirements of Insurance Article, §27-803, Annotated Code of Maryland; and

(b) This chapter.

(2) If the Commissioner has not disapproved an antifraud plan or amendment within 30 days of its filing, the plan shall be deemed approved.

(3) Under §D(1) of this regulation, if the Commissioner determines that an insurer's antifraud plan and any subsequent amendment is not in compliance, the Commissioner shall disapprove the plan or amendment and send a written notice of disapproval with the reasons for disapproval to the insurer.

(4) If the insurer's antifraud plan is disapproved by the Commissioner, the insurer shall submit a new plan to the Commissioner within 60 days after the date the plan was disapproved.

E. This regulation does not apply to third party administrators (TPAs) that only participate in federal programs and are therefore required to file a federal antifraud plan provided that:

(1) Such a federal antifraud plan has been filed with the Centers for Medicare & Medicaid Services;

(2) The TPA provides the federal antifraud plan at the Commissioner's request; and

(3) The TPA files a written attestation stating:

(a) The name of the TPA;

(b) The name and title of the employee attesting who has authority to bind the TPA;

(c) That the TPA is required to file an antifraud plan with the federal government; and

(d) The date the TPA filed the antifraud plan with the federal government.