Section 15-110 - Prohibited referrals. - Maryland Statutes

§ 15-110. Prohibited referrals.
 

(a)  Definitions.-  

(1) In this section the following words have the meanings indicated. 

(2) "Health care practitioner" has the meaning stated in § 1-301 of the Health Occupations Article. 

(3) "Health care service" has the meaning stated in § 1-301 of the Health Occupations Article. 

(4) "Prohibited referral" means a referral prohibited by § 1-302 of the Health Occupations Article. 

(b)  Scope of section.- This section applies to insurers and nonprofit health service plans that issue or deliver individual or group health insurance policies in the State. 

(c)  Repayment for prohibited referrals.- An entity subject to this section may seek repayment from a health care practitioner of any moneys paid for a claim, bill, or other demand or request for payment for health care services that the appropriate regulatory board determines were provided as a result of a prohibited referral. 

(d)  Required provisions.- Each individual and group health insurance policy that is issued for delivery in the State by an entity subject to this section and that provides coverage for health care services shall include a provision that excludes payment of any claim, bill, or other demand or request for payment for health care services that the appropriate regulatory board determines were provided as a result of a prohibited referral. 

(e)  Reporting requirements.- An entity subject to this section shall report to the Commissioner and the appropriate regulatory board any pattern of claims, bills, or other demands or requests for payment submitted for health care services provided as a result of a prohibited referral within 30 days after the entity has knowledge of the pattern. 

(f)  Audits or investigations.-  

(1) Notwithstanding any other provision of this section, an entity subject to this section that reimburses for health care services is not required to audit or investigate a claim, bill, or other demand or request for payment for health care services to determine whether those services were provided as a result of a prohibited referral. 

(2) An audit or investigation of a claim, bill, or other demand or request for payment for health care services to determine whether those services were provided as a result of a prohibited referral is not grounds to delay payment or waive the provisions of §§ 15-1004 and 15-1005 of this title. 

(g)  Refunds.- In accordance with § 1-305 of the Health Occupations Article, an entity subject to this section may seek a refund of a payment made for a claim, bill, or other demand or request for payment that is subsequently determined to be for a health care service provided as a result of a prohibited referral. 
 

[An. Code 1957, art. 48A, §§ 354MM, 470CC, 477MM; 1997, ch. 35, § 2.]