Md. Code Regs. 10.67.13.07

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.13.07 - Payment of Fees and Sanctions

A. In the event that a provider's complaint is unsuccessful, the provider is responsible for paying to the IRO the case review charge established by the Department.

B. The case review charge established by the Department shall be based on the contract between the Department and the IRO arrived at through a competitive procurement process.

C. An MCO that is determined by the IRO to have improperly denied, either in whole or in part, a provider's claim on medical necessity grounds is subject to the following:

(1) Within 60 calendar days of the date of an adverse decision by an IRO, the MCO shall fully reimburse the provider for claims determined to be medically necessary by the IRO, including any interest owed under Health Insurance Article, § 15-1005(f), Annotated Code of Maryland; and

(2) Within 60 calendar days of the date of invoice by the IRO, the MCO shall reimburse the IRO the case review charge established by the Department.

D. In the event that the unsuccessful party does not pay the IRO within 60 calendar days of the date of the invoice, the Department shall impose penalties as follows:

(1) First delinquency: 17 percent of the invoice amount;

(2) Second delinquency: 35 percent of the invoice amount; and

(3) Third delinquency: 50 percent of the invoice amount plus:

(a) For providers, suspension from using the independent case review services for 1 year; or

(b) For MCOs, any sanction set forth in COMAR 10.67.73.01A(1)-(5), as determined by the Department.

Md. Code Regs. 10.67.13.07

Regulations .07 recodified from 10.09.86.07 effective 46:22 Md. R. 976, eff. 11/1/2019