MD HB1153

Prohibits insurers, health maintenance organizations, and managed care organizations from using AI, algorithms, or automated tools to downcode claims without clinical documentation review, and bars downcoding based solely on diagnosis codes or targeting providers treating complex/chronic conditions

Requires insurers to notify health care providers within 30 days of intent to downcode a claim, including specific reasons with clinical criteria, original vs. revised codes with reimbursement amounts, and allowing providers 90 days to submit additional documentation

Mandates that final downcoding decisions be made by a board-certified physician in the same specialty as the service under review with actual clinical experience in that treatment area

Classifies downcoding decisions resulting in nonpayment as coverage decisions eligible for appeal, and allows providers to file complaints directly with the Insurance Commissioner without first appealing to the carrier

Imposes fines up to $10,000 per violation and requires carriers to report quarterly on the number of downcode notices sent and claims downcoded; effective October 1, 2026