MD| The Maryland Insurancee Administration Bulletin 2026-9 reiterates that Maryland law prohibits third party payors from “downcoding,” meaning they may not unilaterally change a provider’s submitted service code and pay a lower level based on their own assessment before obtaining necessary supporting information from the provider. Instead, after receiving a claim, a payor may only either pay it as submitted or issue a notice fully or partially denying reimbursement that explains the reason and requests any additional information needed for full payment, and proactive downcoding in lieu of these steps may subject the payor to penalties for delaying claim payments without cause under § 4-113 of the Insurance Article.
If the payor reasonably believes a claim is improperly coded, it may dispute the claim by sending a status notice, requesting additional information under §§ 15-1004, 15-1005 and COMAR 31.10.11.11A(8), then pay or deny once the information is received, with the enrollee or provider retaining appeal rights under § 15-10D-02. Following an audit showing a pattern of improper coding by a provider, COMAR 31.10.11.10A(10) allows the payor to require documentation supporting the billing code to accompany future claims for them to qualify as clean claims, but it still may not unilaterally alter billing codes.
Click here to see MD Bulletin 2026-9