Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS
Chapter 31.12.08 - Payments to Nonparticipating Providers
Section 31.12.08.05 - Evaluation and Management Services
Universal Citation: MD Code Reg 31.12.08.05
Current through Register Vol. 51, No. 19, September 20, 2024
A. If a nonparticipating provider submits a claim to a health maintenance organization for a covered evaluation and management service, the health maintenance organization shall pay the nonparticipating provider, less any applicable copayment, coinsurance or deductible amount, an amount not less than the greater of:
(1) 125 percent of the fee for the covered evaluation and management service in the annual fee schedule applicable to similarly licensed providers in the same geographic area; or
(2) 140 percent of the fee for the covered evaluation and management service paid by Medicare as published by the Centers for Medicare and Medicaid Services as of August 1, 2008, inflated by the four quarter moving average percent change in the Medicare Economic Index from 2008 to the current year.
B. The Maryland Health Care Commission may publish on its website each year by October 15:
(1) A list of covered services that qualify as Berenson-Eggers Type of Service Code evaluation and management services; and
(2) The inflation factor applicable for inflating 2008 fees to the current year using four quarter moving average percent change for the previous calendar year second quarter.
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