Md. Code Regs. 10.09.41.12

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

Section 10.09.41.12 - Fraud, Liens, Recovery, and Reimbursement

A. The provisions of COMAR 10.09.24.14A concerning fraud apply to this chapter.

B. The Department shall make a claim against income or resources, or both, of a recipient for benefits correctly paid, or to be paid, under the circumstances specified in COMAR 10.09.24.15A -1.

C. The Department may impose a lien on the property of a recipient under the circumstances specified in COMAR 10.09.24.15A -2(1).

D. The Department shall seek recovery of Medical Assistance benefits correctly paid as provided in COMAR 10.09.24.15A -3.

E. The Department shall accept reimbursement if voluntarily offered by a current or former recipient or by someone acting on behalf of the current or former recipient.

F. Extended Benefits Pending a Hearing Decision.

(1) The Department shall refer for reimbursement consideration all cases in which:

(a) A recipient received extended benefits pending a hearing and decision by the hearing officer; and

(b) The hearing officer affirmed the decision of the Department that was the subject of the appeal.

(2) The Department:

(a) Shall institute procedures to recover the cost of any expenditures made on behalf of a recipient in cases identified in §F(1) of this regulation; and

(b) May not apply §F(2)(a) of this regulation to an individual who requested a hearing and extended benefits based on a bona fide belief that the adverse action was erroneous.

G. The Department shall refer for investigation and other appropriate action all cases in which a recipient has received coverage erroneously as a result of the action or inaction of the recipient, representative, or individual acting responsibly for the recipient.

H. The Department shall investigate and take appropriate action in all cases in which eligibility has been incorrectly established as a result of the action or inaction of a recipient, representative, or individual acting responsibly for the recipient.

I. Providers.

(1) If a recipient has ESI or other coverage, or if any other individual is obligated, either legally or contractually, to pay for, or to reimburse the recipient for, services covered by this chapter, a provider of covered services shall seek payment from that source before submitting a claim to the Medical Assistance Program.

(2) If an insurance carrier rejects the provider's claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Medical Assistance Program, which shall be accompanied by a copy of the insurance carrier's notice or remittance advice.

(3) If payment is made by both the Medical Assistance Program and the insurance or other source for the same service, the provider shall refund to the Department, within 60 days of receipt, the amount paid by the Medical Assistance Program or the insurance or other source, whichever is less.

(4) A provider shall reimburse the Department for any overpayment.

J. Recipients. A recipient shall assist and cooperate with the Department's efforts to collect available health insurance benefits and other third party payments by:

(1) Completing a form designated by the Department to report all pertinent information to assist the Department in seeking reimbursement for services provided;

(2) Notifying the Department within 10 days if medical treatment has been provided as a result of any accident or other occurrence in which a third party may be liable for health care services provided to the recipient; and

(3) Providing to the Department, as set forth in §J(2) of this regulation, the information required under such circumstances pursuant to COMAR 10.09.24.12 and Regulation .09B(1)(d) of this chapter.

Md. Code Regs. 10.09.41.12

Regulations .12 adopted as an emergency provision effective April 1, 2006 (33:9 Md. R. 795); adopted permanently effective July 3, 2006 (33:13 Md. R. 1063)
Regulation .12J amended as an emergency provision effective October 1, 2008 (35:22 Md. R. 1955); amended permanently effective February 9, 2009 (36:3 Md. R. 208)
Regulation .12 amended effective 42:3 Md. R. 316, eff.2/16/2015