Sec. 14.09.08.06. Reimbursement Procedures

A. To obtain reimbursement under this chapter, an authorized provider shall:

(1) Complete Form CMS-1500 in accordance with the written instructions posted on the Commission's website; and

(2) Within the time provided in §H of this regulation, submit to the employer or insurer the completed Form CMS-1500, which shall include:

(a) An itemized list of each service;

(b) The diagnosis relative to each service;

(c) The medical records related to the service being billed;

(d) The appropriate CPT/HCPCS code with CPT modifiers, if any, for each service;

(e) The date of each service;

(f) The specific fee charged for each service;

(g) The tax ID number of the provider;

(h) The professional license number of the provider; and

(i) The National Provider Identifier (NPI) of the provider.

B. Modifiers.

(1) Modifying circumstances may be identified by use of the relevant CPT modifier in effect when the medical service or treatment was provided.

(2) The identification of modifying circumstances does not imply or guarantee that a provider will receive reimbursement as billed.

C. Time for Reimbursement. Reimbursement by the employer or insurer shall be made within 45 days of the date on which the Form CMS-1500 was received by the employer or insurer, unless the claim for treatment or services is denied in full or in part under §G of this regulation.

D. Untimely Reimbursement. If an employer or insurer does not pay the fee calculated under this chapter or file a notice of denial of reimbursement, within 45 days of receipt of the CMS-1500, the Commission may assess a fine against the employer or its insurer, and award interest to the provider in accordance with Labor and Employment Article, §§9-663 and 9-664, Annotated Code of Maryland, and COMAR 14.09.06.02.

E. Denial of Reimbursement.

(1) If an employer or insurer denies, in full or in part, a claim for treatment or services, the employer or insurer shall:

(a) Notify the provider of the reasons for the denial in writing; and

(b) Mail the notice of denial of reimbursement to the provider within 45 days of the date on which Form CMS-1500 was received.

(2) An employer or insurer who fails to file a notice of denial of reimbursement within 45 days of receipt of the CMS-1500 waives the right to deny reimbursement, and is subject to the provisions of Labor and Employment Article, §§9-663 and 9-664, Annotated Code of Maryland, and COMAR 14.09.06.02

F. Objection to Denial of Reimbursement.

(1) A provider may contest a partial or total denial of reimbursement, by submitting to the Commission the following items:

(a) A "Claim for Medical Services" on a form provided by the Commission;

(b) The Form CMS-1500 that relates to the unpaid claims; and

(c) All correspondence relating to the unpaid claim.

(2) The Commission shall review the items submitted, without hearing, and issue its decision in an Order Nisi.

G. Hearing on Objection to Commission's Order Nisi.

(1) The provider, employer, or insurer may contest the Commission's Order Nisi by filing with the Commission a controversion of medical claim, on a form provided by the Commission, within 30 days of the date of the Order Nisi.

(2) The Commission shall schedule a hearing on the matter and render a decision.

H. Time for Submitting Form CMS-1500.

(1) A provider who provides medical service or treatment to a covered employee and seeks reimbursement under this chapter for providing medical service or treatment shall submit to the employer or the employer’s insurer a bill in the form of a completed Form CMS-1500 within 12 months from the later of the date:

(a) Medical service or treatment was provided to a covered employee;

(b) The claim for compensation was accepted by the employer or the employer’s insurer; or

(c) The claim for compensation was determined by the Commission to be compensable.

(2) The employer or the employer’s insurer may not be required to pay a bill submitted after the time period required under §H(1) of this regulation unless:

(a) The provider files an application for payment with the Commission within 3 years from the later of the date:

(i) Medical service or treatment was provided to the covered employee;

(ii) The claim for compensation was accepted by the employer or the employer’s insurer; or

(iii) The claim for compensation was determined by the Commission to be compensable; and

(b) The Commission excuses the untimely submission for good cause.