MARYLAND

2017 Maryland Code

Insurance

Title 14 - Entities That Act as Health Insurers

Subtitle 2 - Preferred Provider Organizations

§ 14-205.3. Assignment of benefits

Universal Citation: MD Ins Code § 14-205.3 (2017)

• (a) Applicability. -- This section does not apply to on-call physicians or hospital-based physicians.

• (b) Limitations on insurer regarding assignment and reimbursement. -- An insurer may not:

  • (1) prohibit the assignment of benefits to a provider who is a physician by an insured; or
  • (2) refuse to directly reimburse a nonpreferred provider who is a physician under an assignment of benefits.

• (c) Information with payment. -- If an insured has not provided an assignment of benefits, the insurer shall include the following information with the payment to the insured for health care services rendered by the nonpreferred provider who is a physician:

  • (1) the specific claim covered by the payment;
  • (2) the amount paid for the claim;
  • (3) the amount that is the insured's responsibility; and
  • (4) a statement instructing the insured to use the payment to pay the nonpreferred provider in the event the insured has not paid the nonpreferred provider in full for the health care services rendered by the nonpreferred provider.

• (d) Information required prior to performing a health care service. -- If a physician who is a nonpreferred provider seeks an assignment of benefits from an insured, the physician shall provide the following information to the insured, prior to performing a health care service:

  • (1) a statement informing the insured that the physician is a nonpreferred provider;
  • (2) a statement informing the insured that the physician may charge the insured for noncovered services;
  • (3) a statement informing the insured that the physician may charge the insured the balance bill for covered services;
  • (4) an estimate of the cost of services that the physician will provide to the insured;
  • (5) any terms of payment that may apply; and
  • (6) whether interest will apply and, if so, the amount of interest charged by the physician.
• (e) Submission of disclosure form. -- A physician who is a nonpreferred provider shall submit the disclosure form developed by the Commissioner under subsection (f) of this section to document to the insurer the assignment of benefits by an insured.
• (f) Development of disclosure forms. -- The Commissioner shall develop disclosure forms to implement the requirements under subsections (c) and (d) of this section.

• (g) Refusal to directly reimburse. -- Notwithstanding the provisions of subsection (b) of this section, an insurer may refuse to directly reimburse a nonpreferred provider under an assignment of benefits if:

  • (1) the insurer receives notice of the assignment of benefits after the time the insurer has paid the benefits to the insured;
  • (2) the insurer, due to an inadvertent administrative error, has previously paid the insured;
  • (3) the insured withdraws the assignment of benefits before the insurer has paid the benefits to the nonpreferred provider; or
  • (4) the insured paid the nonpreferred provider the full amount due at the time of service.

Source: § 14-205.3