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

SB 797 prohibits insurers, nonprofit health service plans, HMOs, and managed care organizations from downcoding healthcare claims (reducing reimbursement without proper justification) in specific situations. The bill requires these entities to provide healthcare providers with a 30-day notice before downcoding, including the specific reason, original and revised codes, and an opportunity to submit additional documentation. It bans practices like using algorithms without clinical review, downcoding based solely on diagnosis codes, or targeting providers treating complex conditions. This directly affects healthcare providers and insurers by establishing clear rules for claim reimbursement and appeal processes.