HB 1464

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