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PARRIS N. GLENDENING, Governor Ch. 123
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(2) USE A PRIVATE REVIEW AGENT THAT DOES NOT HOLD A
CERTIFICATE ISSUED UNDER SUBTITLE 10B OF THIS TITLE.
(E) AN ENTITY THAT VIOLATES ANY PROVISION OF THIS SECTION IS SUBJECT
TO THE PENALTIES PROVIDED UNDER § 15-10B-12 OF THIS TITLE.
15-10B-01.
(a) In this subtitle the following words have the meanings indicated.
(b) (1) "Adverse decision" means a utilization review determination made by
a private review agent that a proposed or delivered health care service:
(i) is or was not medically necessary, appropriate, or efficient; and
(ii) may result in noncoverage of the health care service.
(2) [There is no adverse decision if the private review agent and the
health care provider on behalf of the patient reach an agreement on the proposed or
delivered health care services.] "ADVERSE DECISION" DOES NOT INCLUDE A
DECISION CONCERNING A SUBSCRIBER'S STATUS AS A MEMBER
(c) "Certificate" means a certificate of registration granted by the
Commissioner to a private review agent.
(d) (1) "Employee assistance program" means a health care service plan
that, in accordance with a contract with an employer or labor union:
(i) consults with employees or members of an employee's family or
both to:
1. identify the employee's or the employee's family member's
mental health, alcohol, or substance abuse problems; and
2. refer the employee or the employee's family member to
[health care providers] A PHYSICIAN OR PROVIDER LICENSED OR AUTHORIZED TO
PROVIDE HEALTH CARE SERVICES or other community resources for counseling,
therapy, or treatment; and
(ii) performs utilization review for the purpose of making claims or
payment decisions on behalf of the employer's or labor union's health insurance or
health benefit plan.
(2) "Employee assistance program" does not include a health care service
plan operated by a hospital solely for employees, or members of an employee's family,
of that hospital.
(E) (1) "GRIEVANCE" MEANS A PROTEST FILED BY A PATIENT OR A HEALTH
CARE PROVIDER ON BEHALF OF A PATIENT WITH A PRIVATE REVIEW AGENT
THROUGH THE PRIVATE REVIEW AGENT'S INTERNAL GRIEVANCE PROCESS
REGARDING AN ADVERSE DECISION CONCERNING A PATIENT.
(2) "GRIEVANCE" DOES NOT INCLUDE A VERBAL REQUEST FOR
RECONSIDERATION OF A UTILIZATION REVIEW DETERMINATION.
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- 747 -
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