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.

D. A third-party payor shall accept current coding changes by the effective date of the changes set forth by the developers of the codes.

E. If a referral is required under Regulation .10 of this chapter, a third party payor may not deny a claim on the basis that a referral was not received unless the third party payor could not identify the member using the member's name and the following information specified on the referral form:

(1) Date of birth;

(2) Subscriber's plan identification number; or

(3) Other personally identifying information.