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§ 15-10B-17. Patient referral requirements

West's Annotated Code of MarylandInsurance

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 15. Health Insurance
Subtitle 10b. Private Review Agents (Refs & Annos)
MD Code, Insurance, § 15-10B-17
§ 15-10B-17. Patient referral requirements
Currentness
Application of section
(a)(1) Except as provided in paragraph (2) of this subsection, this section does not apply to:
(i) a private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization;
(ii) a preferred provider organization network of participating health care providers or facilities to which the individual would otherwise be referred as part of the individual's membership or insurance contract; or
(iii) an employee assistance program referring an individual to a network of participating health care providers or facilities in accordance with a contract with the individual's employer or labor union to provide comprehensive mental health and substance abuse services.
(2) A private review agent or any other individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may not approve or fail to approve a course of treatment based on whether the treatment is delivered by a provider who is a participating or nonparticipating provider in the preferred provider organization or employee assistance program network.
Conflicts of interest prohibited
(b) A private review agent or any individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may not:
(1) refer a patient who has undergone utilization review by the private review agent to:
(i) a health care facility in which the private review agent owns a significant beneficial interest; or
(ii) the private review agent's own health care practice;
(2) pay or agree to pay any sum to, or accept or agree to accept any sum from, any person for bringing or referring a patient to the private review agent; or
(3) provide for different insurance coverage or benefits based on receiving the service from a health care facility or health care provider in which the private review agent owns a significant beneficial interest.
Referral of patient to another health care provider
(c) A private review agent or any individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may refer a patient who has undergone utilization review by the private review agent to another health care provider regulated under the Health Occupations Article if:
(1)(i) the patient or provider requests the private review agent to provide the patient with the name of a health care provider appropriate to meet the health care needs of the patient; or
(ii) the patient has no attending physician; and
(2) the private review agent provides the patient with the names of at least two health care providers appropriate to meet the health care needs of the patient.

Credits

Added by Acts 2000, c. 123, § 1, eff. Jan. 1, 2001.
MD Code, Insurance, § 15-10B-17, MD INSURANCE § 15-10B-17
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.
End of Document