COMAR 31.10.31 · Chapter 31 Behavioral Health Care Expense Form

.01 Scope. A. This chapter applies to each carrier that provides behavioral health care services through: (1) A company owned wholly or partly by the carrier; or (2) A contract with a managed behavioral health care organization. B. This chapter does not apply to a person that, for an administrator fee only, solely arranges a provider panel for a carrier for the provision of behavioral health care services on a discounted fee-for-service basis.

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.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) Behavioral Health Care Administrative Expenses. (a) "Behavioral health care administrative expenses" means any expenses that are for administrative functions including: (i) Billing and collection expenses; (ii) Accounting and financial reporting expenses; (iii) Quality assurance and utilization management program or activity expenses; (iv) Promotion and marketing expenses; (v) Taxes, fees, and assessments; (vi) Legal expenses; (vii) Salary expenses for employees that are not related to the delivery of behavioral health care services to patients; (viii) Computer expenses; (ix) Provider credentialing; (x) Collection and administrative review of treatment plans; (xi) Auditing the financial report submitted to the Commissioner under Insurance Article, §15-127, Annotated Code of Maryland ; (xii) Debt payment and debt service; and (xiii) Other general and administrative expenses. (b) "Behavioral health care administrative expenses" does not include expenses incurred for behavioral health care services. (2) Behavioral Health Care Services. (a) "Behavioral health care services" means procedures or services rendered by a health care provider for the treatment of mental illness, emotional disorders, drug abuse, or alcohol abuse. (b) "Behavioral health care services" includes any quality assurance or utilization management activities or treatment plan reviews that are clinical in nature. (c) "Behavioral health care services" does not include administrative functions. (3) "Carrier" means: (a) A health insurer; (b) A nonprofit health service plan; (c) A health maintenance organization; (d) A preferred provider organization; (e) A third party administrator; or (f) Except for a managed care organization as defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, any other person that provides health benefit plans subject to regulation by the State. (4) "Direct behavioral health care expenses" means any payment to a health care provider by a managed behavioral health care organization for the provision of behavioral health care services to a member. (5) "Direct payments" means the money that a carrier disburses to a managed behavioral health care organization for the provision of behavioral health care services to a member. (6) "Managed behavioral health care organization" means a company, organization, private review agent, or subsidiary that: (a) Contracts with a carrier to provide, undertake to arrange, or administer behavioral health care services to members; or (b) Otherwise makes behavioral health care services available to members through contracts with health care providers. (7) Member. (a) "Member" means an individual entitled to behavioral health care services from a carrier or a managed behavioral health care organization under a policy or plan issued or delivered in the State. (b) "Member" includes a subscriber. (8) "Provider" means a person licensed, certified, or otherwise authorized under Health Occupations Article, or Health-General Article, Annotated Code of Maryland, to provide health care services.

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.03 Behavioral Health Care Expense Form. Within 90 days after the end of each calendar year, each carrier shall complete the form developed by the Commissioner by obtaining, as necessary, and entering on the form the following information: A. The name of each managed behavioral health care organization with which the carrier has a contract; B. The calendar year for which the data is reported; C. Total direct payments made by the carrier to each managed behavioral health care organization during the calendar year; D. Direct behavioral health care expenses during the calendar year; E. Amounts included in direct behavioral health care expenses for quality assurance or utilization management activities or treatment plan reviews; F. Behavioral health care administrative expenses during the calendar year; and G. The name, title, telephone number, and signature of the individual completing the form and the date that the form was completed.

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.04 Maintenance of Form. A. A carrier shall maintain each form that the carrier is required to complete under Regulation .03 of this chapter for at least 5 years after the date that the form is required to be completed. B. A carrier may maintain a form in paper, photographic, microprocessed, magnetic, mechanical, electronic, digital, or any other media provided that the form is maintained in a manner that: (1) Is clear and legible; (2) Reproduces accurately the original form in its entirety, including any attachments to the form; (3) Is capable of producing a clear and legible hard copy of the original form; and (4) Preserves evidence of the signature contained on the original form. C. A carrier shall make copies of each form that the carrier is required to complete and maintain publicly available to an individual, enrollee, or member, on request, and may charge: (1) A reasonable preparation fee not to exceed $15 for each form requested; and (2) The actual cost for any postage and handling required to provide copies of the requested forms.

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