Md. Code Regs. 31.10.11.14

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.11.14 - Claims Data Filing

A. Required.

(1) Except as provided in §B(2) of this regulation, twice each calendar year a third-party payor shall submit to the Commissioner a claims data filing that documents the payment and denial practices for claims from health care practitioners, hospitals, and other persons entitled to reimbursement of:

(a) The third-party payor; and

(b) Each entity to which the third-party payor has delegated claims processing.

(2) Each claims data filing required pursuant to this regulation shall include, at a minimum, data documenting:

(a) The number of claims received;

(b) The number of claims received that were clean claims pursuant to Regulations .08, .09, and .10 of this chapter;

(c) Claims for which additional information was requested by the third-party payor, or the entity to which the third-party payor has delegated claims processing, pursuant to Regulation .11 of this chapter; and

(d) As to all claims received, compliance or noncompliance with the requirements of Insurance Article, § 15-1005, Annotated Code of Maryland, including timeliness of processing claims and paying interest.

B. Filing Deadlines.

(1) The claim data filing shall be in the form approved by the Commissioner and shall be submitted to the Commissioner not later than:

(a) September 1 of each year, beginning on September 1, 2002, for all claims received for the period of January 1-June 30 of the same calendar year; and

(b) March 1 of each year, beginning on March 1, 2003, for all claims received for the period of July 1-December 31 of the preceding calendar year.

(2) If the Commissioner has evidence that a third-party payor, or an entity to which a third-party payor has delegated claims processing, is not in compliance with Insurance Article, § 15-1003, 15-1004, or 15-1005, Annotated Code of Maryland, the Commissioner may require a third-party payor to submit a claims data filing more frequently than twice a year.

C. Use of Data by Commissioner. The Commissioner shall use the claims data filings to determine the general business practices of third-party payors and entities to which third-party payors have delegated claims processing pursuant to Insurance Article, § 15-1005 , Annotated Code of Maryland.

D. Confidentiality of Information.

(1) A claims data filing submitted to the Commissioner pursuant to this regulation is confidential commercial information pursuant to State Government Article, § 10-617, Annotated Code of Maryland.

(2) Except as provided in §D(3) of this regulation, the Commissioner shall deny inspection of a claims data filing.

(3) If information from a claims data filing is used as the basis for imposing interest or penalties on a third-party payor, the information shall be available for public inspection only as to the portions pertinent to the imposition of interest or penalties.

E. The Commissioner may impose penalties if a third-party payor submits inaccurate information required by §A of this regulation, in an amount not to exceed the penalty amount set forth in Insurance Article, § 4-113(d)(1), Annotated Code of Maryland.

F. The Commissioner may act in accordance with Insurance Article, § 4-113(b) or (d), Annotated Code of Maryland, if a third-party payor willfully submits inaccurate information required by §A of this regulation.

Md. Code Regs. 31.10.11.14

Amended effective 44:4 Md. R. 256, eff. 2/27/2017