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Ch. 123
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2000 LAWS OF MARYLAND
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[(7)] (8) 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;
[(8)] (9) a list of the health care providers AS DEFINED IN § 15-10B-07 OF
THIS SUBTITLE PERSONS involved in establishing the specific criteria and standards
to be used in conducting utilization review; and
[(9)] (10) 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.
(b) (1) At least [10] 30 days before a private review agent requires any
revisions or modifications to [the] EXISTING specific criteria and standards to be
used in conducting utilization review of proposed or delivered services, the private
review agent shall submit those revisions or modifications to the Commissioner.
(2) AT LEAST 10 DAYS BEFORE A PRIVATE REVIEW AGENT REQUIRES
SPECIFIC CRITERIA AND STANDARDS TO BE USED IN CONDUCTING UTILIZATION
REVIEW OF PROPOSED OR DELIVERED SERVICES IN WHICH THERE ARE NO EXISTING
CRITERIA OR STANDARDS, THE PRIVATE REVIEW AGENT SHALL SUBMIT THE
CRITERIA AND STANDARDS TO THE COMMISSIONER
(c) 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 or modifications 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.
(d) The private review agent may charge a reasonable fee for a copy of the
specific criteria and standards or any subsequent revisions or modifications
REVISIONS, MODIFICATIONS. OR ADDITIONS to the specific criteria to any person or
health care facility requesting a copy under subsection (c) of this section.
(e) [It shall constitute a violation of this subtitle if the Commissioner, in
consultation with an independent review organization, medical expert, the
Department of Health and Mental Hygiene, or other appropriate entity, determines
that the criteria and standards used in conducting utilization review are not:
(1) objective;
(2) clinically valid;
(3) compatible with established principles of health care; or
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- 752 -
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