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§ 15-10B-05. Utilization review plan requirements

West's Annotated Code of MarylandInsuranceEffective: June 1, 2016

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 15. Health Insurance
Subtitle 10b. Private Review Agents (Refs & Annos)
Effective: June 1, 2016
MD Code, Insurance, § 15-10B-05
§ 15-10B-05. Utilization review plan requirements
Currentness
Utilization review plan submitted to Commissioner
(a) In conjunction with the application, the private review agent shall submit information that the Commissioner requires including:
(1) a utilization review plan that includes:
(i) the specific criteria and standards to be used in conducting utilization review of proposed or delivered health care services;
(ii) those circumstances, if any, under which utilization review may be delegated to a hospital utilization review program; and
(iii) if applicable, any provisions by which patients, physicians, or hospitals may seek reconsideration;
(2) the type and qualifications of the personnel either employed or under contract to perform the utilization review;
(3) a copy of the private review agent's internal grievance process if a carrier delegates its internal grievance process to the private review agent in accordance with § 15-10A-02(l) of this title;
(4) the procedures and policies to ensure that a representative of the private review agent is reasonably accessible to patients and health care providers 7 days a week, 24 hours a day in this State;
(5) if applicable, the procedures and policies to ensure that a representative of the private review agent is accessible to health care providers to make all determinations on whether to authorize or certify an emergency inpatient admission, or an admission for residential crisis services as defined in § 15-840 of this title, for the treatment of a mental, emotional, or substance abuse disorder within 2 hours after receipt of the information necessary to make the determination;
(6) the policies and procedures to ensure that all applicable State and federal laws to protect the confidentiality of individual medical records are followed;
(7) a copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan;
(8) a list of the third party payors for which the private review agent is performing utilization review in this State;
(9) the policies and procedures to ensure that the private review agent has a formal program for the orientation and training of the personnel either employed or under contract to perform the utilization review;
(10) a list of the persons involved in establishing the specific criteria and standards to be used in conducting utilization review; and
(11) certification by the private review agent that the criteria and standards to be used in conducting utilization review are:
(i) objective;
(ii) clinically valid;
(iii) compatible with established principles of health care; and
(iv) flexible enough to allow deviations from norms when justified on a case by case basis.
Specific criteria and standards used in conducting utilization review
(b) On the written request of any person or health care facility, the private review agent shall provide 1 copy of the specific criteria and standards to be used in conducting utilization review of proposed or delivered services and any subsequent revisions, modifications, or additions to the specific criteria and standards to be used in conducting utilization review of proposed or delivered services to the person or health care facility making the request.
Fees for copy of specific criteria and standards
(c) The private review agent may charge a reasonable fee for a copy of the specific criteria and standards or any subsequent revisions, modifications, or additions to the specific criteria to any person or health care facility requesting a copy under subsection (b) of this section.
Changes in ownership, name and address, and scope of responsibility
(d) A private review agent shall advise the Commissioner, in writing, of a change in:
(1) ownership, medical director, or chief executive officer within 30 days of the date of the change;
(2) the name, address, or telephone number of the private review agent within 30 days of the date of the change; or
(3) the private review agent's scope of responsibility under a contract.

Credits

Added by Acts 1988, c. 703, § 1, eff. Dec. 1, 1988. Amended by Acts 1991, c. 363, § 1, eff. July 1, 1991; Acts 1992, c. 581, § 1, eff. Oct. 1, 1992. Transferred from Health - General § 19-1305 and amended by Acts 1998, c. 111, §§ 1, 2, eff. Jan. 1, 1999; Acts 1998, c. 112, §§ 1, 2, eff. Jan. 1, 1999; Acts 1999, c. 34, § 1, eff. April 13, 1999. Amended by Acts 2000, c. 123, § 1, eff. Jan. 1, 2001; Acts 2006, c. 331, § 1, eff. Oct. 1, 2006; Acts 2016, c. 121, § 1, eff. June 1, 2016.
MD Code, Insurance, § 15-10B-05, MD INSURANCE § 15-10B-05
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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