§ 15-10B-07. Adverse decisions and appeals
West's Annotated Code of MarylandInsurance
MD Code, Insurance, § 15-10B-07
§ 15-10B-07. Adverse decisions and appeals
(a)(1) Except as provided in paragraphs (2) and (3) of this subsection, all adverse decisions shall be made by a physician, or a panel of other appropriate health care service reviewers with at least one physician on the panel who is board certified or eligible in the same specialty as the treatment under review.
(b) All adverse decisions shall be made by a physician or a panel of other appropriate health care service reviewers who are not compensated by the private review agent in a manner that violates § 19-705.1 of the Health-General Article or that deters the delivery of medically appropriate care.
(c) Except as provided in subsection (d) of this section, if a course of treatment has been preauthorized or approved for a patient, a private review agent may not retrospectively render an adverse decision regarding the preauthorized or approved services delivered to that patient.
(d) A private review agent may retrospectively render an adverse decision regarding preauthorized or approved services delivered to a patient if:
(e) If a course of treatment has been preauthorized or approved for a patient, a private review agent may not revise or modify the specific criteria or standards used for the utilization review to make an adverse decision regarding the services delivered to that patient.
Credits
Added by Acts 2000, c. 123, § 1, eff. Jan. 1, 2001.
MD Code, Insurance, § 15-10B-07, MD INSURANCE § 15-10B-07
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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