Md. Code Regs. 31.10.11.10

Current through Register Vol. 51, No. 18, September 6, 2024

Section 31.10.11.10 - Attachments to Uniform Claims Forms

A. A third-party payor may require a health care practitioner, hospital, or person entitled to reimbursement to include any of the following attachments to a HCFA Form UB-92 or HCFA Form 1500, respectively, for a claim to qualify as a clean claim:

(1) A referral or consultant treatment plan submitted by the specialist, if the claim is for specialty services under an HMO plan or in-network point-of-service plan, unless the third-party payor requires the provider of primary care services to submit directly to it the referral or consultant treatment plan for specialty services;

(2) An explanation of benefits statement from the primary payor to the secondary payor, unless an electronic remittance notice has been sent by the primary payor to the secondary payor;

(3) A Medicare remittance notice, if the claim involves Medicare as a primary payor and the third-party payor provides evidence that it does not have a crossover agreement to accept an electronic remittance notice;

(4) A description of the procedure or service, which may include the medical record, if a procedure or service rendered has no corresponding Current Procedural Terminology (CPT) or HCPCS code, or additional description information relating to a CDT code;;

(5) Operative notes, if the claim is for multiple surgeries, or includes modifier 22, 58, 62, 66, 78, 80, 81, or 82;

(6) Anesthesia records documenting the time spent on the service, if the claim for anesthesia services rendered includes modifiers P4 or P5;

(7) Documents referenced as contractual requirements in the global contract, if there is a global contract between a third-party payor and a health care practitioner, hospital, or person entitled to reimbursement;

(8) An ambulance trip report, if the claim is for ambulance services submitted by an ambulance company licensed by the Maryland Institute for Emergency Medical Services Systems;

(9) Office visit notes, if the claim includes modifier 21 or 22;

(10) Information related to the audit as specified in writing by the third-party payor, if the third-party payor's audit of the health care practitioner, hospital, or person entitled to reimbursement demonstrated a pattern of fraud, improper billing, or improper coding;

(11) Admitting notes, except in the case of services rendered in accordance with Health-General Article, §§19-701(d) and 19-712.5, Annotated Code of Maryland, if the claim is for inpatient services provided outside of the time or scope of the authorization;

(12) Physician notes, except in the case of services rendered in accordance with Health-General Article, §§19-701(d) and 19-712.5, Annotated Code of Maryland, if the claim for services provided is outside of the time or scope of the authorization, or when there is an authorization in dispute;

(13) Itemized bills, except in the case of services rendered in accordance with Health-General Article, §§19-701(d) and 19-712.5, Annotated Code of Maryland, if the claim is for services:

(a) Rendered in a hospital and the hospital claim has no prior authorization for admission, or

(b) Inconsistent with a third-party payor's concurrent review determination rendered before the delivery of services, regarding the medical necessity of the service;

(14) Adjunct claims documentation pursuant to Health-General Article, §19-710.1(b)(3), Annotated Code of Maryland;

(15) A treatment plan from a child's health care practitioner that includes one or more specific treatment goals, if the claim is for habilitative services for a child diagnosed with autism or autism spectrum disorder.

B. In its manual, or other document that sets forth the claim filing procedures pursuant to Insurance Article, § 15-1004(d), Annotated Code of Maryland, a third-party payor shall:

(1) List the attachments to an HCFA Form UB-92 or HCFA Form 1500 that it may require under §A of this regulation for a claim to qualify as a clean claim; and

(2) Describe the circumstances under which each attachment may be required.

C. A third-party payor may accept any additional attachments with the HCFA Form 1500 or HCFA Form UB-92.

Md. Code Regs. 31.10.11.10

Regulation .10A amended effective41:5 Md. R. 348, eff.3/17/2014