Provider Issues

​Physicians and health providers: please find below information about how to file a complaint, credentialing for fully insured health plans, and prompt payment of claims. If you have questions please contact our Life and Health Complaint Unit at 410.468-2244.
 
If you are a consumer, please see our consumer section for help. If you are looking for a provider in your health plan network, contact your insurance company or HMO.
 

Prompt Pay and Clean Claims

 


Maryland’s Prompt Pay law is stated in 
§ 15-1005 of the Insurance Article. It applies to health policies issued in Maryland by insurers, nonprofit health services plans, health maintenance organizations, and managed care organizations (carriers). It does not apply to Medicare, including Medicare Advantage plans, or the Federal Employee Health Benefit Program. To the extent that the prompt payment law is consistent with ERISA, it may apply to self-funded benefit plans offered by employers, where the insurer, nonprofit health service plan, or health maintenance organization provides only administrative services. Property and casualty claims, including PIP and Worker’s Compensation claims, are not subject to the law.

This law requires payment within 30 days of receipt of a “clean” claim.  Clean claims, and the information a carrier may request, are defined in COMAR 31.10.11.  If a claim is not clean or is in dispute, notice stating the specific information required to process the claim must be sent within 30 days after receipt.  Interest is required to be paid along with late claim payments. For a detailed understanding of the law, you should read the statute and regulations.

To file a complaint about a possible violation of the Prompt Pay law, you can use our online system.

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 and member identification card, if available. If additional information was requested by the carrier, include the claim number, and the date of re-submission.​

Retroactive denial of claims/recoupment

 
Section 15-1008 of the Insurance Article​ limits when a carrier may retroactively deny reimbursement of a health claim that has already been paid to the provider. In general, a carrier is limited to six months from the date a claim is paid to retroactively deny the claim.

If the retroactive denial is due to fraud or miscoding, there is no time limit for the denial. If the retroactive denial is due to coordination of benefits, the time limit is 18 months from the date of payment, and the carrier must give notice that includes the primary carrier’s name and address.  In a case involving a coordination of benefits, you have six months to file the claim with the primary carrier.

A carrier can reimburse itself by reducing future payments owed to a provider  if the carrier provides timely notice of the retroactive denial.

To file a complaint about retroactive denial of claims, you can use our online system​.​

Credentialing

 
Maryland’s credentialing law is in § 15-112​ of the Insurance Article. The statute deals with multiple aspects of how carriers contract with providers for participation on a provider panel.  “Within 30 days of receiving an application, a carrier must send notice of the carrier’s intent to continue to process the application or a rejection of the application. If a carrier proceeds with processing the application, the carrier has 120 days after the date of the notice to accept or reject the provider for participation and send notice of the decision. If an application is incomplete, the carrier must return the application within 10 days.

Section 15-112.1 of the Insurance Article requires a carrier to accept the uniform credentialing form submitted to it by a provider. A carrier may not request information that is not part of the uniform credentialing form.  The Council for Affordable Quality Healthcare, Inc. (CAQH) online form has been designated as the uniform credentialing form.

It is always best to consult with an attorney if you have questions relating to signing a provider panel contract.

To file a complaint about credentialing delays or problems, you can use our online system.​​

When you are not on a carrier's or HMO's provider panel

 
  • HMO members

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.
  • PPO or EPO members

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.
 
  • Complaints about the amount of payment

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. ​