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PARRIS N. GLENDENING, Governor Ch. 123
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(2) dispenses drugs, medical devices, medical appliances, or medical
goods for the treatment of a human disease or dysfunction; OR
(3) PROVIDES ANY OTHER CARE, SERVICE, OR TREATMENT OF DISEASE
OR INJURY, THE CORRECTION OF DEFECTS, OR THE MAINTENANCE OF THE
PHYSICAL AND MENTAL WELL-BEING OF HUMAN BEINGS.
(J) "HEALTH CARE SERVICE REVIEWER" MEANS AN INDIVIDUAL WHO IS
LICENSED OR OTHERWISE AUTHORIZED TO PROVIDE HEALTH CARE SERVICES IN
THE ORDINARY COURSE OF BUSINESS OR PRACTICE OF A PROFESSION.
[(g)] (K) "Private review agent" means:
(1) a nonhospital-affiliated person or entity performing utilization
review that is either affiliated with, under contract with, or acting on behalf of:
(i) a Maryland business entity; or
(ii) a third party that [provides] PAYS FOR, PROVIDES, or
administers [hospital benefits] HEALTH CARE SERVICES to citizens of this State[,
including:
1. a health maintenance organization issued a certificate of
authority in accordance with Title 19, Subtitle 7 of the Health - General Article; or
2. a health insurer, nonprofit health service plan, health
insurance service organization, or preferred provider organization authorized to offer
health insurance policies or contracts in this State in accordance with this article]; or
(2) any person or entity including a hospital-affiliated person
performing utilization review for the purpose of making claims or payment decisions
FOR HEALTH CARE SERVICES on behalf of the employer's or labor union's health
insurance plan under an employee assistance program for employees other than the
employees EMPLOYED BY:
(i) [employed by] the hospital; or
(ii) [employed by] a business wholly owned by the hospital.
[(h)](L) "Significant beneficial interest" means the ownership of any financial
interest that is greater than the lesser of:
(1) 5 percent of the whole; or
(2) $5,000.
[(i)] (M) "Utilization review" means a system for reviewing the appropriate
and efficient allocation of health care RESOURCES AND services given or proposed to
be given to a patient or group of patients.
[(j)] (N) "Utilization review plan" means a description of the standards
governing utilization review activities performed by a private review agent.
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- 749 -
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