Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.11 - Uniform Claims Forms
Section 31.10.11.10 - Attachments to Uniform Claims Forms

Universal Citation: MD Code Reg 31.10.11.10

Current through Register Vol. 51, No. 19, September 20, 2024

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.

Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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