Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.13 - Provider Contracts

Current through Register Vol. 51, No. 14, July 12, 2024
A. All signed written agreements, including those defining physicians' services, shall be on file and available for review by the Commissioner at all times in the HMO's central office.
B. If agreements with consultants or other institutions are established by any HMO, the responsibilities, functions, objectives, and the terms of the agreements including financial arrangements and charges, of each outside resource shall be described in writing and signed by an authorized representative of the facility and the person or the agency providing the services.
C. Filing Requirements.
(1) The HMO may not use a provider contract unless the form of the contract has been filed in duplicate with the Commissioner.
(2) The HMO shall file a provider contract at least 30 days before its intended use.
(3) Form Numbers.
(a) The provider contract shall be identified by a unique form number that appears in the lower left corner of the first page of the provider contract.
(b) Each amendment rider to a provider contract shall be identified by a unique form number that appears in the lower left corner of the first page of the amendment rider.
(4) If the HMO intends to amend any of the following provisions of a previously filed provider contract, the HMO shall file the amendment with the Commissioner at least 30 days before its intended use:
(a) The hold-harmless clause;
(b) Any provision dealing with the administration of a coordination of benefits clause;
(c) Any provision dealing with termination of the provider contract, as described in Insurance Article, §
											15-112, Annotated Code of Maryland;
(d) Any provision dealing with the process of filing or payment of claims, as described in Insurance Article, §§
											15-1004 and  15-1005, Annotated Code of Maryland;
(e) Any provision dealing with when capitation payments are due for newly assigned HMO members, as described in Insurance Article, §
											15-113, Annotated Code of Maryland;
(f) Any provision dealing with retroactive denials of reimbursement or denials of reimbursement for preauthorized care, as described in Insurance Article, §§
											15-1008 and  15-1009, Annotated Code of Maryland;
(g) Any provision dealing with the payment of bonuses or other incentive-based compensation, as described in Insurance Article, §
											15-113, Annotated Code of Maryland, but actual payment amounts or percentages are not required to be filed;
(h) Any provision requiring the health care provider to provide services to other than HMO members or giving the health care provider an option to provide services to other than HMO members, as described in Insurance Article, §
											15-112, Annotated Code of Maryland;
(i) Any provision that gives the HMO the right to assign, transfer or subcontract a health care provider's contract to an insurer that offers personal injury protection coverage, as described in Insurance Article, §
											15-125, Annotated Code of Maryland;
(j) Any provision dealing with a provider's responsibility for the acts or decisions of the HMO, as described in Health-General Article, §19-710, Annotated Code of Maryland;
(k) Any provision dealing with the applicability of Maryland law; or
(l) Any provision of the contract that is revised to comply with Maryland law.