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:

(a) There is no authorization; or

(b) There was preauthorization and the third-party payor disputes the claim:

(i) Consistent with the bases for a carrier's denial as set forth in Insurance Article, §15-1009(b), Annotated Code of Maryland, or

(ii) Because the claim is for services provided outside of the time or scope of the authorization and the applicable attachment required in Regulation .10 of this chapter was not submitted with the claim;

(2) Eligibility for benefits or coverage in accordance with Insurance Article, §15-1004(e)(1), Annotated Code of Maryland;

(3) The appropriateness of a service, procedure, or durable medical equipment rendered or provided by a specialist not requested by the primary care provider of an enrollee of a health maintenance organization on a referral form or consultant treatment plan;

(4) In the case of a claim made pursuant to a global contract, the information necessary to adjudicate the claim consistent with the global contract;

(5) A reasonable belief of incorrect billing in accordance with Insurance Article, §15-1005(c)(2)(ii), Annotated Code of Maryland;

(6) The insured's or enrollee's liability for the service under the insurance policy or contract, subject to the third-party payor obtaining the additional information from its insured or enrollee within 30 days from receipt of the claim;

(7) Legibility of the claim in a material matter;

(8) A reasonable belief of fraudulent or improper coding consistent with the bases for a carrier's retroactive denial as set forth in Insurance Article, §15-1008(e), Annotated Code of Maryland;

(9) A reasonable belief that a claim for emergency services may not meet the standards for an emergency service pursuant to Health-General Article, §19-701(d), Annotated Code of Maryland;

(10) The essential information required for a third-party payor to adjudicate a claim for dental services; and

(11) A category approved by the Commissioner by regulation.

B. A third-party payor may not request additional information if an attachment containing the same type of information was submitted with the claim pursuant to Regulation .10 of this chapter.

C. Except as provided for in §A(1) and (2) of this regulation, a third-party payor may not request medical records if:

(1) The claim is for services as set forth in Regulation .10A(12) of this chapter; and

(2) An itemized bill was submitted with the claim.

D. The following are impermissible categories of disputed claims for which third-party payors may not request additional information pursuant to Insurance Article, §§15-1004(c) and 15-1005(c), Annotated Code of Maryland:

(1) Except for global contracts, a description of the procedure or service that is inconsistent with the applicable standard code set;

(2) Reimbursement for hospital services, in accordance with the rates approved by the Health Services Cost Review Commission pursuant to Insurance Article, §15-1214, Annotated Code of Maryland; and

(3) Except for the bases for a carrier's denial of reimbursement for preauthorized or approved services as set forth in Insurance Article, §15-1009(b), Annotated Code of Maryland, services that were preauthorized by the third-party payor or a private review agent.