If you provide covered services to a member of an HMO, which may include obtaining prior authorization, and are not a contracting provider, an HMO is required to pay the claim in accordance with § 19-710.1 of the Health-General Article. Billing the patient for any amount other than coinsurance, copayment, or deductible is prohibited by § 19-710 of the Health-General Article.

 

A provider who is an on-call physician and who accepts assignment of benefits for health care services rendered to an insured in a hospital, and covered under a preferred provider individual or group insurance policy is reimbursed based on § 14-205.2 of the Insurance Article.  The claim should be billed with CPT code 99026 or its successor. The insured cannot be billed any amount other than coinsurance, copayment, or deductible.

 

A provider who is a hospital-based physician and who accepts assignment of benefits for health care services rendered to an insured in a hospital, and covered under a preferred provider individual or group insurance policy is reimbursed based on § 14-205.2 of the Insurance Article. The insured cannot be billed any amount other than coinsurance, copayment, or deductible.

 

A provider who is an on-call physician who does not accept assignment of benefits may charge the patient usual billed charges. The carrier may reimburse the patient directly. The carrier is required only to pay the allowed amount as defined in the member’s policy or certificate of coverage.

 

A provider who provides out-of-network services, and is not an on-call or hospital-based physician, may collect usual billed charges from the patient. A physician who provides the disclosure described in § 14-205.3 of the Insurance Article​ may be paid directly based on an assignment of benefits. The carrier is required to pay only the allowed amount as defined in the member’s policy or certificate of coverage.

 

If you have a complaint that the amount paid is less than the amount specified in your contract with the carrier (or the carrier’s provider panel subcontractor), or the member’s policy or certificate of coverage if you are out-of-network, you may file a complaint through our online system. Partial denials of claims, including denials of the amount between the allowed amount and billed charges, are subject to § 15-10D-02 of the Insurance Article​​. An appeal must be filed with the carrier prior to filing a complaint with the Maryland Insurance Administration. If you have multiple complaints about the same carrier, please provide a representative sample of no more than 10 claims. Include the date of service, date of submission, how it was submitted (electronic or paper), and a copy of the claim form, EOB, appeal, appeal response, and member identification card, if available. ​​