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EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
*hb1464*
HOUSE BILL 1464
J5 6lr2041
By: Delegate Guzzone
Introduced and read first time: February 13, 2026
Assigned to: Health
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Third–Party Administrators – Verification of Eligibility 2
FOR the purpose of requiring third –party administrator s of plan s that provide health 3
benefits to develop a process through which a health care provider can request 4
information to determine the eligibility of an enrollee and the administrator can 5
respond to a request in a timely manner ; prohibiting certain carriers from 6
retroactively denying reimbursement to a provider who used a certain process to 7
confirm an enrollee was eligible for certain services; and generally relating to 8
third–party administrators. 9
BY adding to 10
Article – Insurance 11
Section 8–310.1 12
Annotated Code of Maryland 13
(2017 Replacement Volume and 2025 Supplement) 14
BY repealing and reenacting, with amendments, 15
Article – Insurance 16
Section 15–1008 17
Annotated Code of Maryland 18
(2017 Replacement Volume and 2025 Supplement) 19
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 20
That the Laws of Maryland read as follows: 21
Article – Insurance 22
8–310.1. 23
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AN ADMINISTRATOR OF A PLAN THAT PROVIDES HEALTH BENEFITS SHAL L 1
DEVELOP A STREAMLINED PROCESS THROUGH WHICH: 2
(1) A HEALTH CARE PROVID ER CAN REQUEST WHETHER AN 3
ENROLLEE IS ELIGIBLE TO RECEIVE A COVERED HEALTH CARE SERVICE UNDER THE 4
PLAN; AND 5
(2) THE ADMINISTRATOR CAN RESPOND IN A TIMELY MANNER TO ANY 6
ELIGIBILITY REQUEST MADE UNDER ITEM (1) OF THIS SECTION. 7
15–1008. 8
(a) (1) In this section the following words have the meanings indicated. 9
(2) “Carrier” means: 10
(i) an insurer; 11
(ii) a nonprofit health service plan; 12
(iii) a health maintenance organization; 13
(iv) a dental plan organization; 14
(v) a managed care organization, as defined in § 15 –101 of the 15
Health – General Article; or 16
(vi) any other person that provides health benefit plans subject to 17
regulation by the State. 18
(3) “Code” means: 19
(i) the applicable current procedural terminology (CPT) code, as 20
adopted by the American Medical Association; 21
(ii) if for a denta l service, the applicable code adopted by the 22
American Dental Association; or 23
(iii) another applicable code under an appropriate uniform coding 24
scheme used by a carrier in accordance with this section. 25
(4) “Coding guidelines” means those standards o r procedures used or 26
applied by a payor to determine the most accurate and appropriate code or codes for 27
payment by the payor for a service or services. 28
HOUSE BILL 1464 3
(5) “Health care provider” means a person or entity licensed, certified or 1
otherwise authorized under the Health Occupations Article or the Health – General Article 2
to provide health care services. 3
(6) “Reimbursement” means payments made to a health care provider by a 4
carrier on either a fee–for–service, capitated, or premium basis. 5
(b) This section does not apply to an adjustment to reimbursement: 6
(1) made as part of an annual contracted reconciliation of a risk sharing 7
arrangement under an administrative service provider contract; or 8
(2) made as part of a two–sided incentive arrangement that complies with 9
§ 15–113 of this title. 10
(c) (1) If a carrier retroactively denies reimbursement to a health care 11
provider, the carrier: 12
(i) may only retroactively deny reimbursement for services subject 13
to coordination of benefits with another carrier, the Maryland Medical Assistance Program, 14
or the Medicare Program during the 18 –month period after the date that the carrier paid 15
the health care provider; and 16
(ii) except as provided in item (i) of this paragraph, may only 17
retroactively deny reimbursement during the 6–month period after the date that the carrier 18
paid the health care provider. 19
(2) (i) A carrier that retroactively denies reimbursement to a health 20
care provider under paragraph (1) of this subsection shall provide the health care provider 21
with a written statement specifying the basis for the retroactive denial. 22
(ii) If the retroactive denial of reimbursement results from 23
coordination of benefits by a carrier that is not a managed care organization, the written 24
statement shall provide the name and address of the entity acknowledging responsibility 25
for payment of the denied claim. 26
(d) Except as provided in subsection (e) of this section, a carrier [that does not 27
comply with the provisions of subsection (c) of this section ] may not ret roactively deny 28
reimbursement or attempt in any manner to retroactively collect reimbursement already 29
paid to a health care provider IF: 30
(1) THE CARRIER DOES NOT COMPLY WITH SUBSECTION (C) OF THIS 31
SECTION; OR 32
(2) BEFORE PROVIDING THE SERVICE, THE HEALTH CARE PROVIDER 33
INQUIRED IN GOOD FAI TH ABOUT THE ENROLLE E’S ELIGIBILITY UNDER § 8–310.1 34
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OF THIS ARTICLE AND RECEIVED CONFIRMATIO N FROM THE THIRD –PARTY 1
ADMINISTRATOR THAT T HE ENROLLEE WAS ELIG IBLE FOR THE SERVICE , 2
REGARDLESS OF THE ENROLLEE’S ACTUAL ELIGIBILITY STATUS. 3
(e) (1) The provisions of subsection (c)(1) of this section do not apply if a carrier 4
retroactively denies reimbursement to a health care provider because: 5
(i) the information submitted to the carrier was fraudulent; 6
(ii) the information submitted to the carrier was improperly coded 7
and the carrier has provided to the health care provider sufficient information regarding 8
the coding guidelines used by the carrier at least 30 days prior to the date the services 9
subject to the retroactive denial were rendered; 10
(iii) the claim submitted to the carrier was a duplicate claim; or 11
(iv) for a claim submitted to a managed care organization, the claim 12
was for services provided to a Maryland Medical Assistance Program recipient duri ng a 13
time period for which the Program has permanently retracted the capitation payment for 14
the Program recipient from the managed care organization. 15
(2) Information submitted to the carrier may be considered to be 16
improperly coded under paragraph (1) of this subsection if the information submitted to the 17
carrier by the health care provider: 18
(i) uses codes that do not conform with the coding guidelines used 19
by the carrier applicable as of the date the service or services were rendered; or 20
(ii) does not otherwise conform with the contractual obligations of 21
the health care provider to the carrier applicable as of the date the service or services were 22
rendered. 23
(f) If a carrier retroactively denies reimbursement for services as a result of 24
coordination of benefits under provisions of subsection (c)(1)(i) of this section, the health 25
care provider shall have 6 months from the date of denial, unless a carrier permits a longer 26
time period, to submit a claim for reimbursement for the service to the carri er, Maryland 27
Medical Assistance Program, or Medicare Program responsible for payment. 28
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 29
October 1, 2026. 30