Maryland Medical Assistance Program and Health Insurance - Claims for Reimbursement - Downcoding

HB 1153 prohibits health insurers, nonprofit health service plans, HMOs, and managed care organizations in Maryland from unilaterally lowering medical claim payments (downcoding) without clinical justification. The bill requires these entities to notify providers within 30 days if they intend to downcode, including specific reasons, references to clinical guidelines, and the original vs. revised codes. It bans practices like downcoding based solely on diagnosis codes, using AI without reviewing medical records, or targeting providers treating complex conditions, and mandates emergency claims be downcoded based on documented symptoms - not final diagnoses. A downcoding decision resulting in nonpayment is treated as a coverage denial, allowing providers to appeal under existing law.