Health Maintenance Organization and Dental Plan Orgainzation Provider Contract Filing Instructions

LARRY HOGAN Governor BOYD K. RUTHERFORD Lt. Governor MARYLAND INSURANCE ADMINISTRATION AL REDMER, JR. Commissioner NANCY GRODIN Deputy Commissioner 200 St. Paul Place, Suite 2700, Baltimore, Maryland 21202 1-800-492-6116 TTY: 1-800-735-2258 www.insurance.maryland.gov # BULLETIN 17-11 Date: October 30, 2017 To: Health Maintenance Organizations and Dental Plan Organizations Re: Provider Contract Filing & Instructions The purpose of this Bulletin is to remind health maintenance organizations (“HMO”) and dental plan organizations¹ (“DPO”) of the filing requirements for provider contracts with the Maryland Insurance Commissioner (“Commissioner”). # Health Maintenance Organization Filing Requirements A provider contract is a written agreement under which a healthcare provider agrees to provide healthcare services to HMO enrollees. This includes: - An arrangement where an HMO contracts directly with healthcare providers; - An Administrative Service Provider Contract;² - A contract between contracting providers and external providers;³ or - A contract between a provider and an intermediary organization that arranges for providers to serve enrollees of an HMO. COMAR 31.12.02.13C requires an HMO to file a provider contract with the Commissioner at least 30 days prior to use. Additionally, if an HMO amends any of the provisions listed in COMAR 31.12.02.13C(4) of a previously filed provider contract, the amendment must be filed with the Commissioner at least 30 days prior to use. Additional guidance about administrative service provider contracts was previously provided under Life and Health Bulletin 00-13, dated June 7, 2000 and Life and Health Bulletin 00-26, dated December 22, 2000. These bulletins are available on the Administration’s website at http://insurance.maryland.gov. ¹ Dental plan organizations include nonprofit health service plans that limit their operation to dental services. COMAR 31.12.04.02B(6)(b). ² See § 19-713.2 of the Health-General Article, Annotated Code of Maryland. ³ See id. # Dental Plan Organization Filing Requirements A DPO provider contract is “a contract between a dental plan organization or entity acting on behalf of the dental plan organization and a plan dentist.”⁴ This includes for example, a contract between a dentist and an intermediary organization that arranges for dentists to serve enrollees of a DPO. Section 14-405(b)(5) of the Insurance Article and COMAR 31.12.04.09A(5) require a DPO provider contract form to be submitted with the DPOs application for a certificate of authority. Pursuant to § 14-406 of the Insurance Article, if a DPO significantly modifies the provider contract form that it intends to use in Maryland, it must be submitted to the Commissioner within ten (10) days. DPO’s are reminded to periodically review their DPO provider contracts to ensure such changes comply with applicable requirements, including §§ 15-112 and 15-112.2, and are submitted to the Commissioner as required. The filings required by this bulletin are to be filed with the Rates and Forms Unit of the Life and Health Section of the Maryland Insurance Administration and may be submitted electronically as a confidential filing through SERFF. Questions about this bulletin may be directed to the Life and Health Section at 410-468-2170. Al Redmer, Jr. Commissioner By: Robert D. Morrow Jr. Associate Commissioner Life & Health ⁴ COMAR 31.12.04.02B(13).